PRE-INTAKE SURVEY

First Name: Enter First Name

Email: Enter Email

Address: Enter Address

City: Enter City

State: Enter State

Zip code: Enter Zip

Phone: Enter Phone Number

Date of Call/Inquiry: Enter Date

Last Name: Enter Last Name

How did you hear about the NELCDC?

A friend

A Lender

Other Source

Name of Lender

Other Source:

What would you like to achieve working with NELCDC?

Purchase of a Home

Improve my Credit

Financial Independence

Other:

Refinance

Home Equity Loan

Foreclosure/Loss Prevention

Fair Housing Inquiry / Complaint

Other:

Have you taken NELCDC’s Financial Literacy/Homebuyer Education Workshop?

Yes

No

If yes, what month and year:

When is the best day(s) for you to meet with a Housing Counselor? You may specify more than one day.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Daytime (8am-5pm)

Lunch hour

Evenings

Weekends

Other

Other Times:

Please specify a best time to meet: Enter day and time

Do you have other availability specifics or special needs:

Please specify a best time to call: Enter Text

Confirm cell phone number: Enter cell phone number

Would you like to receive text from NELCDC to remind you of your appointment?

Yes

No

Image Verification:

Is a referral necessary?

Yes

No

I don't know.

If Yes, provide details. Enter Your Message