510-833-2154 EXT 5

Housing Counseling

Intake Form

To retrieve the results of the form, sign into swbintakes@gmail.com.
Date First & Last Name Contact Phone Number E-mail What is your mailing address?
Are You Homeless
Yes
No
What is Your Case Worker Name, Organization Name and Phone Number and Email Address?
Are you over the age of 65 yrs old?
Yes
No
Are you under the age of 18yrs old?
Yes
No
What is your source of income?
Do you have a valid ID?
Yes
No
In progress
Do you have a valid social security card or US Citizen authorization?
Yes
No
In progress
How many people living in your household? Do you need housing special accommodations? If so, please explain. What County would you like to secure housing?
Do you need any resources for medical, mental, drug or alcohol treatments?
Yes
No
Do you have access to a computer?
Yes
No
Are there any other resources we can help you with? If so, please explain:
Have you reviewed your credit report within the last 30 days?
Yes
No
Your credit counseling appointment is scheduled on: Your Credit Counselor Name is: Who referred you to our organization? Your Housing Counselor Name: Your next housing counseling appointment is scheduled: Housing Counselor Notes I agree to the Terms & Conditions and Privacy Policy Submit