AHA Intake Form

First Name Required Field

Last Name

Reason For Contact Required Field

Phone

Address 1

Address 2

City

State

Zip/Postal Code Required Field

County You Are Requesting Assistance In Required Field

Date of Birth Required Field

Gender

Race/Ethnicity Required Field

Current Living Arrangements Required Field

Disability Status Required Field

Disability Type Required Field

Current Employer Name Required Field

Employer Address Required Field

Rate Your Credit Status Required Field

Income Status Required Field

Annual Income Required Field

Select all Sources of Income (Ctrl+Click) Required Field

Do You Receive Rental Assistance (ie. Section 8) ? Required Field

Marital Status Required Field

How many people in your household Required Field

Number of Adults Required Field

Number of Children Required Field

Are You Currently Serving in the Military Required Field

Are You A Veteran Required Field

Are You The Spouse Of A Veteran Required Field

How Did You Hear About Us Required Field

What kind of assistance are you requesting?