Survey Intake Form

Name *

First

Last

Email *

Phone *

Are you currently in need of immediate housing assistance? *

How many people are in your household (including yourself)? *

Phone receiving receiving?

Which county do you currently reside in? *

What is your total household income? *

Are you currently receiving rental assistance? *

What kind of rental assistance are you receiving? *

If none, just write N/A

Is your debt maximum: $5000 or more? *

What is your current living situation? *

Have you experienced any evictions in the last five years? *

Have you been employed for at least six consecutive months? *

What services are you interested in? (Select all that apply) *

What size unit are you looking for? *

Qualification is dependent on income. Please only choose a 2+ Bedroom unit if you make more than $3600 in total household income.