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)? *

Which county do you currently reside in? *

What is your total household income? *

What kind of rental assistance are you receiving? *

If none, just write N/A

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

last yourself)? you

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

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