OFF-CAMPUS HOUSING INTAKE FORM
Student information sheet
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Name (First): *
Name (Last):
Age in years: *
Gender (Pick all that apply):   *
Required
Are you a first generation college student?
Clear selection
Are you or have you serving/served in the military?
Clear selection
Ethnicity/Race (Pick all that apply) : *
Required
Phone Number(s) (In this format: Cell 707-555-1212) *
Do you work?
Clear selection
How much do you earn per month? *
Are you receiving any resources/benefits for yourself? *
Do you need any other services that could help fulfill your Basic Needs (Housing, Food, Mental Health, Job, etc.) ?
What benefits are you receiving? *
Required
Are you interested in learning about community resources for students? *
Are you interested in attending an Educated Renters Program? *
What Kind of housing are you looking for?
Where would you like to live? *
Required
What housing concerns do you have? *
How much would you like to spend on rent and utilities? *
Where are you moving from? *
Who are you moving with? *
Do you have Children/Dependents? *
How many?
Do you have a pet?   *
What kind?
Do you have an Emotional Support Animal, or a Service Animal? *
Are you having issues with your roommate? (Please explain).
Do you need assistance with a landlord dispute? (Please explain).
Are you having trouble with a property manager? (Please explain).
Do you have legal questions around housing practices, disputes, or contracts for housing? (Please explain).
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