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CDC-HPE Assessment Intake Form
Please provide us with the following information. Information collected on this form is used by Central Detroit Christian only. Please answer all questions completely. if you have any questions about this form and how we will use this information, please contact us.

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About Central Detroit Christian
CDC is a non-profit, HUD approved, comprehensive housing counseling agency. We serve all clients regardless  of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and federal anti-discrimination laws. As a housing counseling program participant, you are not obligated to use the products and services of Central Detroit Christian or our industry partners.
Name *
Email *
Complete Address (including zip code) *
Phone number *
How did you hear about Central Detroit Christian? *
Occupant's relationship to the property. *
How long have you been living in the property? (years) *
REASON FOR LOSS OF PROPERTY? (briefly describe) *
Gender *
Ethnicity *
Race *
Number of persons in household *
Marital Status *
Date of Birth *
MM
/
DD
/
YYYY
Primary language spoken in household (English, Spanish, French, Arabic, etc..)
Are you a first time home buyer? *
Current housing situation *
Are there any children under 6 or pregnant in home *
Live in a rural area *
Annual Income *
Disabled *
Veteran *
Education *
Currently Working?
Clear selection
Employment status *
Length of employment (in years).
Length of unemployment (in years)
Receiving child support payments or alimony? *
Receiving  Social Security Retirement or Disability Insurance? *
Receiving other pension or retirement insurance? *
Receiving Veteran's Benefits? *
Receiving Public Assistance? *
What type of benefits are being received? *
Initials *
Do you need help finding resources or programs: (Please check all that apply).
Event date (CDC will complete this information)
MM
/
DD
/
YYYY
Class ID# (CDC will complete this information
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