HCEC Intake Form

Homeless Information

Are you currently homeless (living on the street, your car or other non residential setting)?

Yes
No

Being homeless can include being doubled up or 'couch surfing' with family or friends. Does this describe your living circumstances?

Yes
No

Date of Birth

Multiple Choice

Female
Male
Transgender
Choose not to respond

What is your preferred language?

Please CHECK ALL that apply to you:

Landlord's Name

Education Level

Have you ever served in the military even for a short time?

Yes
No

If Yes, which branch:

Ethnicity

Hispanic
Non Hispanic

Race

Other Race

What services are you seeking?

Financial Assistance for a Housing Crisis (homelessness/eviction/utility shut off/foreclosure)
Housing & Legal Counseling for Tenants and Landlords
Community and/or Court-Connected Mediation/Dispute Resolution Services
Berkshire Consumer Services Program
Housing Search
Foreclosure Prevention & Homeowner Assistance
Tenancy Preservation Program (TPP)

If you are seeking financial assistance, have you had or already had an increase or decrease in income or expenses?

Yes
No

If you need to move, do you have a new apartment?

Yes
No

How much is the new monthly rent?

At Risk of Homelessness (Please choose all that apply)

How much rent do you owe?

How many months are you behind in rent?

How many months are you behind?

Housing Search Assistance

I need help finding a permanent place to live
I stay in a shelter at night
I live on the street and need help finding housing
I want to talk about getting a housing subsidy

Are you a victim of domestic violence/abuse?

Yes
No

How much do you owe on your mortgage?

If yes, how long ago or are you currently experiencing abuse?

Other housing instability circumstances:

I pay more than 50% (half) my income to my housing costs
I would like to learn more about becoming a first-time homebuyer
I am out of heating fuel
I need help dealing with my landlord to get repairs done
I have issues with my landlord/property manager
I am behind in my utility bills and have shut off notices.
I need help making my home accessible for a disabled person
Do you have a housing subsidy (such as Section 8) or live in public housing?

What kind of housing subsidy do you have? (Section8, MRVP, Public Housing, Rent is based on your income)

Did you apply for or already receive fuel assistance at Berkshire Community Action Council (BCAC) this season?

Yes
No

If you have applied for or received fuel assistance this season, how long ago/when?

Fair Housing:

I feel that I have been discriminated against for housing
I have been denied housing

Source of Income (check all that apply):

Other Source(s) of Income (please list)

Gross Monthly Income (before taxes & deductions). Include all household member's income:

Add together all income from all household members. Calculate the total into a monthly amount. If calculating wages or income from a business or job, use the gross amount, which is the total earned before any deductions or taxes are taken out.

Food Stamps/SNAP

How much is your monthly SNAP benefit (food stamps)?

How much is your monthly Rent/Mortgage expense?

Price: $0.00

For mortgage, include your total mortgage payment if it includes escrow (insurance & taxes).

How much are your monthly heating/fuel/electric expenses?

Include all sources of fuel for heat and electric in a monthly total cost.

Have you been employed in the past five years?

Yes
No

If Yes, you have been in the last five years or are currently employed, what is the name of the employer or business?

Do you have a checking or savings account, stocks or other assets?

Yes
No

List the total amount of checking & savings accounts, stocks, etc.

Number of adults living in your household:

If you are homeless, this would be the number of adults who are part of your household unit and would move with you to a permanent apartment rental.

Are you pregnant?

Yes
No

How many children/dependents (under age 21) are living in your household?

Yes
No

Anyone under the age of 21 living in your household should be counted. If you are homeless, this would include all members of your household unit that would move with you to a permanent apartment rental.

Please list the ages of all dependents in your household.

If you are homeless, please list ages of dependents that would move with you to a permanent apartment rental.

Is anyone in your household disabled?

Yes
No

Please explain why you are requesting assistance today:

The Violence Against Women Reauthorization Act of 2005 (VAWA):

The Violence Against Women Reauthorization Act of 2005 (VAWA) prohibits denial of assistance to admission to an otherwise qualified participant on the basis that the participant is or has been a victim of domestic violence, dating violence or stalking. Specifically, Section 606 (1) of VAWA adds the following provisions to Section 8 of the U.S. Housing Act of 1937, which lists contract provisions and requirements for the Section 8 Housing Choice Voucher Program: That the application or participant has been a victim of domestic violence, dating violence, or stalking is not an appropriate reason for denial of program assistance or for denial of admission, if the applicant otherwise qualifies for assistance or admission.

UpSide413: SERVICES DISCLOSURE STATEMENT & CONSENT OF RELEASE OF INFORMATION:

Upside413 provides the following housing counseling services: Rental and Fair Housing counseling for tenants and landlords, Mortgage Delinquency and Default counseling for homeowners, Homelessness Prevention and Resolution Services, and Dispute Resolution Programming. In addition, Upside413 offers the Tenancy Preservation Program and the Consumer Counseling Program. Housing Counseling clients are not obligated to use any other product or services offered by this agency, its affiliates, or partners. Upside413 will provide information on alternative services, programs, and products. Clients should consider a variety of resources and options and upon evaluation select resources that best meet their needs. Financial support for the Housing Counseling Program is provided by some of the following organizations: Massachusetts Bar Foundation, HUD Office of Housing Counseling, Division of Banks, and Housing & Consumer Education Centers. I/We understand that it is my/our right and responsibility to decide whether to engage in any course of housing counseling with Upside413 and to determine whether counseling is suitable for my/our housing problem. I/We understand that Upside413 provides information on a broad range of housing programs and products and that the housing counseling I receive from Upside413 in no way obligates me to choose any loan product or housing program discussed in my counseling sessions. I/We understand that Upside413 does not guarantee that I/We will receive mortgage financing form any lender and/or other mortgage financing entity. I/We may be referred to other housing services of the organization or to another agency or agencies as appropriate that may be able to assist with concerns that have been identified. I/We understand that a counselor may answer questions and provide information but cannot give legal advice. If I want legal advice, I will be referred for appropriate assistance. I/We understand that information and data regarding your Housing Counseling case may also be shared with the funders of the program you are participating in with Upside413. The specific funding agencies are HUD and/or Citizens’ Housing and Planning Association (CHAPA). Said information sharing may include allowing access by HUD and/or CHAPA to your file for the purpose of oversight of the grant that funds the program you are participating in through Upside413. I/We understand that information and data regarding my Housing Counseling case may also be shared with Community Legal Aid for the purpose of accessing legal advice pertaining to my housing issue. By typing your full name below, you agree to the Services Disclosure Statement & Consent of Release of Information above.

Consent & Release:

All information presented above, including income of all household members, is true to the best of my knowledge. I understand that by signing below I am giving permission to Hearthway, UpSide413, ServiceNet, Soldier On and all C.O.C. Partnering Agencies to share this Assessment, and other provided information, in order to coordinate the most effective and efficient services to my household. I understand that this permission is given pursuant to Section 2 of Chapter 66A of Massachusetts General Law, the Fair Information Practice Act. This consent automatically expires one year from date signed or when services are terminated, whichever occurs first. By typing your full name in the box below, you agree to the consent and release above.

HCEC Customer Assessment Form

Massachusetts residents - continue here

Homeless Information

The Violence Against Women Reauthorization Act of 2005 (VAWA):

UpSide413: SERVICES DISCLOSURE STATEMENT & CONSENT OF RELEASE OF INFORMATION:

Consent & Release: