AHA Intake Form
Please fill out the information below and an AHA representative will contact you as soon as possible.



If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information
and services about housing counseling, please speak with agency staff about arranging alternative accommodations.
Required FieldFirst Name 
Required FieldLast Name 
Required FieldEmail 
Required FieldReason For Contacting the AHA 
Required FieldDOB Pick
Required FieldGender 
Required FieldRace/Ethnicity 
Required FieldCurrent Living Arrangement 
Required FieldAddress line 1 
Address line 2 
Required FieldCity 
Required FieldState 
Required FieldZip/Postal Code 
Required FieldCounty You Are Requesting Assistance In 
Required FieldPhone Number 
Required FieldDisability Status 
Required FieldType of Disability 
Required FieldName of Current Employer 
Required FieldEmployer Address 
Required FieldRate your Current Credit Status 
Required FieldSelect all Sources of Income (Ctrl+Click) 
Required FieldIncome Status 
Required FieldDo You Receive Rental Assistance (ie. Section 8) ? 
Required FieldAnnual Income 
Required FieldMarital Status 
Required FieldHow Many People Are In Your Family? 
Required FieldNumber of Adults 
Required FieldNumber of Children 
Required FieldAre You a Veteran 
Required FieldAre You the Spouse of a Veteran 
Required FieldHow Did You Hear About Us? 
Is there anything else you would like to tell us?