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Client Intake Form

Client Intake Form

Have Questions? Please fill out our Client Intake form and we will get back to you!

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Date/Time*

Name*

Address*

Best phone number to reach you at*

Email*

What issues brought you in and what are you looking to address?*

Programs you're interested in learning about:*

Rental

Pre-purchase

Housing Ownership & Preservation

Financial Literacy

Unhoused

General Affordable Housing Information

Key Certificate Programs

Unsure or Other

Race*

Hispanic*

Yes

No

Age*

Birthdate*

Gender*

Male

Female

Other/Nonconforming

Housing you want?*

Rental

Buy

Marital Status*

Single (never married)

Married

Divorced

Widow/Widower

English Proficient?*

Yes

No

Are you a veteran?*

Yes

No

Credit Score*

Highest Level of Education:*

High School/GED

Some college/trade school

College

Graduate School

Please check one to describe your current situation*

Rent

Own

Staying with family/friends

Other

If renting, how much do you pay for rent?*

If renting, how long have you lived at this address?*

Annual Household Gross Income*

Number of people in household*

Number of dependents*

Gender and age of each dependent*

Employer 1*

Date you started at Employer 1*

Town you work in for Employer 1*

Job Title at Employer 1*

Income for Employer 1*

Number of years employed at Employer 1*

Employer 2

Date you started at Employer 2

Town you work in for Employer 2

Job Title at Employer 2

Income for Employer 2

Number of years employed at Employer 2

How did you hear about us?*

Website

Facebook/Instagram

Friend/Family

Employer

Other

2nd Household Member Name (if needed)

2nd Household Member Email

2nd Household Member Date of Birth

2nd Household Member Employer

2nd Household Member - date started employment

2nd Household Member - Name of town where employed

2nd Household Member - Job title at this employer

2nd Household Member - income from this employer

2nd Household Member - number of years employed here

3rd Household Member Name (if needed)

3rd Household Member Email

3rd Household Member Date of Birth

3rd Household Member Employer

3rd Household Member - date started employment

3rd Household Member - Name of town where employed

3rd Household Member - Job title at this employer

3rd Household Member - income from this employer

3rd Household Member - number of years employed here

What are your comments/questions?

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Rental
Path to Ownership
Financial Literacy Education

Key Certificate Programs
Other Housing Counseling Services & Resources
Upcoming Webinars & Events

CJHRC
92 East Main Street, Suite 407
Somerville, NJ 08876
908-446-0036
2cjhrc@gmail.com

About Us
Contact Us
Search
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