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THF Intake Form

Client Name*

Date of Birth*

Phone*

Email*

Address*

Client Name 2

Date of Birth 2

Phone

Total # of People in Household*

Number of Dependents*

Total Gross Monthly Income*

Total Monthly Liabilities*

Current Living Situation*

If "Other" Please Explain:

Gender Identity

Veteran Status

Marital Status

Hispanic?

Is someone in the home disabled?

Age(s)

Race(s) (Please list all that apply)

Household Type:*

If "Other" Please Explain:

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Contact

226 E. Nittany Ave., 2nd Floor
State College, PA 16801

814-954-4215

ginger.c@housingtransitions.org

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