Customer Intake Form

Summary

1
STAFF USE: Appointment scheduled ______________________
Documents Given (Date) ______________________
If not; Pre-Adv. Action (Date): ____________________
Adv. Action Letter ______________________ (w/in 5 days of pre)
SS entry _______________ (initial when complete)
Updated 3/16/20 dj
Customer Intake Form
I am interested in housing in: (Mark one or both, if applicable) ____Bend ____ Redmond
___ I have watched the Informational Videos on the website:
Video Code 1: ______________ Video Code 2: ___________ (verification of review)
This form is NOT considered an application for the housing program
Along with this form please turn in 1-3 recent paystub copies or verification of income for each customer
PRIMARY CUSTOMER INFORMATION Please Print Clearly
Name: _____________________________________________________________________________________________________
First MI Last
________________________________________________________________________________________________________________________
Street
________________________________________________________________________________________________________________________
City State Zip Code
Phone: (_____) _______–____________ Email: ___________________________________________________________________
Ethnicity (please check one): ___ Hispanic/Latino ___ Non-Hispanic/Latino
Race (please check one): ___ American Indian or Alaska Native ___ Asian ___ Black or African American
___ Native Hawaiian or Other Pacific Islander ___ White ___ Other
___ 2 or more races
Citizenship (please select one):
___ You are a Citizen or National of the United States
___ You are foreign born and a U.S. Resident (green card holder)
___ You are a Noncitizen with eligible status as evidenced by one of the documents listed below
• Form I551-Alien Registration Receipt Card (for permanent resident aliens)
• Form I-94, Arrival-departure record
• A final court decision or DHS letter granting asylum
___ None of the above – Not contending eligible immigration status, no further information required and the person named above
understands they are not eligible for program selection but agrees to start housing counseling while immigration status changes

Marital Status (please select one): ___ Single ___ Married ___ Divorced ___ Separated ___ Widowed
Gender (please select one): ___ Male ___ Female ___ Other Gender Identity: (Optional) ______________________
Education (please check one):
___ Below High School Diploma ___ High School Diploma or Equivalent
___ Two-Year College ___ Bachelors Degree
___ Masters Degree ___ Above Masters Degree
Do any of the following apply to you? Optional for data collection
___ Hearing difficulty (deaf or having serious difficulty hearing)
___ Vision Difficulty (blind or having serious difficulty seeing, even when wearing glasses)
___ Cognitive difficulty (Because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisions)
___ Ambulatory difficulty (Having serious difficulty walking or climbing stairs)
___ Self-care difficulty (Having difficulty bathing or dressing)
___ Victim of Domestic Violence ___ Recovery from Substance Abuse
bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701
2
Are you a Veteran? ___ Yes ___ No
Current Housing Arrangement (please check one):
___ Rent ___Homeless ___ Living with family member and not paying rent ___ Living with friends or roommates, sharing rent
Health Insurance
Do you currently have health insurance? If no, what prohibits you? ___ Yes ___ No
______________________________________________________________________________________________________
First time Buyer
Do you currently own a home, or have owned a home in the past three years? ___ Yes ___ No
Household Type (please select the most accurate)?
___ Female headed single parent household ___ Male headed single parent household ___ Single adult
___ Two or more unrelated adults ___ Married with children ___ Married without children ___ Other
Family/Household Size: ______ (include those that will be living in the home for more than 6 months of the year)
How many dependents (those claimed on taxes or legal guardian and other than those listed by any co-borrower)? ________
What ages are they? ____,____,____,____,____,____,____,____,____
Do all dependents have healthcare insurance? ___ Yes ___ No
If no, please explain: _____________________________________________________________________________________
Are there non-dependents who will be living in the home? ___ Yes ___ No
If yes, list below:
______________________________________________ ______________________________________________
Relationship Age Relationship Age
Note: All adults over 18 years old, living in the household must submit financial documents so that we can calculate household income
levels

Referred to by (please check all that apply):
___ Print Ad / Newspaper ___ Bank ___ Other Agency ___ Realtor ___ Facebook ___ Employer: ____________
___ Staff/Board member ___ Walk-InFamily/Friend ___ TV /Radio ___ Other: _______________
If you were referred by a Bank or Realtor, which one? _________________________________________________
PRIMARY CUSTOMER EMPLOYMENT — Last 2 Years Please Print Clearly
Primary Employer: ______________________________________________ Work Phone: (_______) _________–______________
_________________________________________________ ____________________
Title Hire Date
___________________________________________________________________________________________________________
Work Address Street City State Zip Code
Employment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________
Gross monthly Income (before taxes): $____________________
Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________
Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthly
If applicable:
Second Employer: ______________________________________________ Work Phone: (_______) _________–______________
bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701
3
_________________________________________________ ____________________ (years, months)
Title Length of Employment
_______________________________________________________________________________________________
Street City State Zip Code
Employment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________
Gross monthly Income (before taxes): $____________________
Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________
Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthly
Previous Employer: _____________________________________________ Work Phone: (_______) _________–______________
_________________________________________________ Length of Employment (dates) ____________________
Title
___________________________________________________________________________________________________________
Street City State Zip Code
___ Part-Time ___ Full-Time Hours per pay period_____________________
Gross monthly Income (before taxes): $____________________
Were you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________
Was your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthly
CO-APPLICANT INFORMATION
Name: _____________________________________________________________________________________________________
First MI Last
________________________________________________________________________________________________________________________
Street
________________________________________________________________________________________________________________________
City State Zip Code
Phone: (_____) _______–____________ Email: ___________________________________________________________________
Ethnicity (please check one): ___ Hispanic/Latino ___ Non-Hispanic/Latino
Race (please check one): ___ American Indian or Alaska Native ___ Asian ___ Black or African American
___ Native Hawaiian or Other Pacific Islander ___ White ___ Other
___ 2 or more races
Citizenship (please select one):
___ You are a Citizen or National of the United States
___ You are foreign born and a U.S. Resident (green card holder)
___ You are a Noncitizen with eligible status as evidenced by one of the documents listed below
• Form I551-Alien Registration Receipt Card (for permanent resident aliens)
• Form I-94, Arrival-departure record
• A final court decision or DHS letter granting asylum
___ None of the above – Not contending eligible immigration status, no further information required and the person named above
understands they are not eligible for program selection but agrees to start housing counseling while immigration status changes

Marital Status (please select one): ___ Single ___ Married ___ Divorced ___ Separated ___ Widowed
Gender (please select one): ___ Male ___ Female ___ Other Gender Identity: (Optional) ______________________
Education (please check one):
___ Below High School Diploma ___ High School Diploma or Equivalent
___ Two-Year College ___ Bachelors Degree ___ Masters Degree ___ Above Masters Degree
bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701
4
Do any of the following apply to you? Optional for data collection
___ Hearing difficulty (deaf or having serious difficulty hearing)
___ Vision Difficulty (blind or having serious difficulty seeing, even when wearing glasses)
___ Cognitive difficulty (Because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisions)
___ Ambulatory difficulty (Having serious difficulty walking or climbing stairs)
___ Self-care difficulty (Having difficulty bathing or dressing)
___ Victim of Domestic Violence ___ Recovery from Substance Abuse
Are you a Veteran? ___ Yes ___ No
Relationship to Customer (please check one): ___ Spouse/Partner ___ Daughter/Son ___ Sister/Brother
___Girlfriend/Boyfriend ___ Mother/Father ___ Other: _______________________________
CO-APPLICANT EMPLOYMENT — Last 2 Years Please Print Clearly
Primary Employer: ______________________________________________ Work Phone: (_______) _________–______________
_________________________________________________ ____________________
Title Hire Date
___________________________________________________________________________________________________________
Work Address Street City State Zip Code
Employment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________
Gross monthly Income (before taxes): $____________________
Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________
Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthly
If applicable:
Second Employer: ______________________________________________ Work Phone: (_______) _________–______________
_________________________________________________ ____________________ (years, months)
Title Length of Employment
_______________________________________________________________________________________________
Street City State Zip Code
Employment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________
Gross monthly Income (before taxes): $____________________
Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________
Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthly
Previous Employer: _____________________________________________ Work Phone: (_______) _________–______________
_________________________________________________ Length of Employment (dates) ____________________
Title
___________________________________________________________________________________________________________
Street City State Zip Code
___ Part-Time ___ Full-Time Hours per pay period_____________________
Gross monthly Income (before taxes): $____________________
bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701
5
Were you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________
Was your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthly
HOUSEHOLD INCOME Please Print Clearly
Estimated Gross Annual Family or Household Income: $______________ (include income from all adults – 18 and older – living in the
household)
Type of Income (List ALL sources of income) BUYER CO-APPLICANT(s) Other Adult in Household
Monthly Amount Monthly Amount Monthly Amount
CO-APPLICANT(s)
Salary, Wages (including Tips)
Alimony/Child Support (children 16 and younger only)
Rental Income
Social Security SSI / SSDI (children 16 and younger
and/or permanent disability only)
Pension/ Retirement Income
Public Assistance (Habitat does not use to calculate income)
Self-employment Income
Dependent SSI Income (children 16 and younger and/or
permanent disability only)
Other Employment (if employed for 2+ years)
LIQUID FUNDS/SAVINGS/INVESTMENTS Please Print Clearly
Please list the approximate value of the following: BUYER CO-APPLICANT(s) Other Adult inCO-APPLICANT(s)
Household
Checking account
Savings account
Checking account
Cash
CDs
Securities (stocks, bonds, etc.)
Retirement account
Other Liquid Funds
HOUSING EXPENSES
BUYER CO-APPLICANT(s) Other Adult inCO-APPLICANT(s)
Household
Current monthly rent
Utilities: Electric/Gas/Solid Waste
Telephone / Cell phone
Cable/Satellite TV
Internet
Other Living Expenses (ie.Storage)
bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701
6
LIABILITIES / DEBT AUTHORIZATION TO RELEASE CREDIT INFORMATION
I authorize the Housing Counseling Staff of Bend-Redmond Habitat for Humanity to:
(a) pull my/our credit report (soft pull; will not affect your score) to review my/our credit file for housing counseling in connection with
my pursuit on a loan to purchase real property;
(b) pull my/our credit report (soft pull) and review my/our credit file for informational inquiry purposes; and
(c) obtain a copy of the HUD-1 Settlement Statement, Appraisal, and Real Estate Note(s) when I/We purchase a home, from the
lender who made me/us a loan and/or the title company that closed the loan

I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability
and/or criminal liability under the provisions of Title 18, United States Code, Section 1001

_________________________________________________________ ____________________
Customer Date
_________________________________________________________ ____________________
Co-Applicant Date
So that we my better counsel you, please complete the financial questionnaire

Please put an “x” in the column that best fits your current situation. As hard as it can sometimes be to think about money
concerns, this will give us an idea of how to best set goals together when we meet to review your mortgage readiness

How often does this happen to you? Often Sometimes Never
1. Not enough money for essentials
2. Behind on rent payments
3. Don’t have enough food until there is more money
4. Are in danger of having utilities turned off
5. Unable to meet large bills
6. Bills are confusing
7. Excessive medical bills
8. Behind in credit card payments
9. Have had action taken by creditor
10. Struggle to discuss finances with family or partner
11. Bills get lost or mailed/paid late
12. Feel stressed about finances
13. Don’t know where money is going
14. Not able to save 10% of income (each month)
Other Yes No
Change in job
Recently divorced or separated
Struggle with some type of addiction
Other:
Other:
What three things do you think are most important to pay first and regularly each month?
1

What financial concern do you want to work on most?
bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701

Customer Intake Form . I am interested in housing in: ____Bend ____ Redmond ___ I have watched the Informational Videos on the website: Video Code 1: _____ Video Code 2: _____ …

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Frequently Asked Questions

What is a client intake form?

A client intake form is a questionnaire that you share with a client at the beginning of a working relationship. With a new client intake form, you can gather the information you need from a client so that you can: Understand if the client is a good fit for your company.

How can i use this universal client intake template?

This universal template accommodates a wide range of business purposes; use it for single client intake or as a template to record multiple clients’ information upon initial contact. You can store this new client information securely or share it with fellow employees and departments in order to keep everyone apprised of new client details.

How can i increase my client intake?

Publicly, by sharing the form on your website. Privately, by sending the form to your prospects or new clients. 1. Using a website client intake form Uploading your client intake form on your website may drive a higher intake.

What is included in a counseling intake form template?

The template has space for you to write down the personal information of the client, citation data, payment records, and other relevant information. With easy-to-fill and comprehensive counseling intake form templates, you can track crucial client details before their first counseling sessions.