HCEC Customer Assessment Form

HCEC Intake Form

The first step in receiving helpful resources starts here.

HCEC can answer questions about all types of housing problems. We help individuals and families find and retain affordable housing.  We are Pittsfield’s largest provider of rental voucher assistance, serving the homeless, the elderly, the disabled, and low and moderate-income residents of the Berkshires.

  • Please, take the time to fill out this form and submit it to us.
  • This is the first step to receiving our help.
  • You can change the language by clicking “English” at the top of the page.
  • Puedes cambiar el idioma a español. Haga clic en “English” en la parte superior de la página.
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Name
Are you currently homeless (living on the street, your car or other non residential setting)?
Being homeless can include being doubled up or 'couch surfing' with family or friends. Does this describe your living circumstances?
Multiple Choice
Please CHECK ALL that apply to you:
Education Level
Have you ever served in the military even for a short time?
Ethnicity
Race
What services are you seeking?
If you need to move, do you have a new apartment?
At Risk of Homelessness (Please choose all that apply)
Housing Search Assistance
Are you a victim of domestic violence/abuse?
Other housing instability circumstances:
Fair Housing:
Source of Income (check all that apply):
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.
Have you been employed in the past five years?
Do you have a checking or savings account, stocks or other assets?
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?
How many children/dependents (under age 21) are living in your household?
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.
Is anyone in your household disabled?
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.

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