HCEC Intake Form

Who referred you/how did you hear about us?

Address

City

ZIP Code

Home Phone

Cell Phone

Work Phone

Alternative Contact Name

Alternative Contact Phone Number

Date of Birth

Gender

Female

Male

Transgender

Would you like to be added to the FCRHRA tenant list serve?

yes

AT RISK OF HOMELESSNESS

I have been denied emergency assistance

I have a notice to quit

I am living doubled-up. I have to move out.

I owe rent and am being evicted

My landlord is being foreclosed upon. I need to move out.

My apartment is in poor condition. I have to move out.

I am a few/many months behind on my mortgage.

HOUSING SEARCH

I need help finding a permanent place to live

I stay in a shelter at night

I live on the street. I need help finding housing

I want to talk about how to get a subsidy

FAIR HOUSING

I feel that I have been discriminated against for housing.

I have been denied housing.

OTHER

I pay 50% or more of my income to my housing costs

I need help making my apartment/home accessible for a disabled family member

I want to buy a house and would like to learn more about how to do that

I need some help to deal with my landlord to get repairs made to my apartment

I am behind on utility bills and I have shut off notices

I am having issues with my landlord-property management issues

I am a landlord having issues with a tenant

I am a victim of domestic violence

Do you have a subsidy or live in public housing?

Are you working with any other agencies? (please list)

What is your preferred language?

Other languages spoken at home

Do you have at least one child under 21 living with you?

Yes

Are you Pregnant?

yes

Does anyone in your household have a disability?

Myself

Family member

Monthly Income gross before taxes

Monthly Rent/Mortgage Payment

Have you ever served on active duty in the military?

yes

not sure

Ethnicity

Not Hispanic

Hispanic

Race

Add a new option to those above

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Education

Homeownership

Municipalities

HCEC Intake Form