Section 1 - Screening Questions

What are you seeking help with today?

Buying my first homePreparing to purchase a homeImproving my credit or budget for homeownershipForeclosure PreventionReverse mortgage (HECM) counselingRental CounselingI need help paying rent, utilities, food, transportation, or finding community resources

Based on your selection, 211 may be better able to assist you. Call 211 or text your zip code to 898-211 to connect with community resources that may meet your needs.

Have you previously received housing counseling from our agency?

Yes No

Section 2 - Contact Information

First Name:

Last Name:

Phone Number:

Email Address:

Preferred Method of Contact for scheduling an appointment:

Phone Email

What is the best time to contact you?

MorningAfternoon

Section 3 - Household Information

If yes, how many months behind?

Street Address:

City:

State:

Zip Code:

County:

Approximate Monthly Household Income:

$

Number of people living in your household:

Section 5 - Tell Us About Your Situation

Please briefly describe why you are seeking housing counseling today.

Section 6 - Consent

I understand:

Completing this form is a request for housing counseling services and does not guarantee eligibility.

A HUD-certified housing counselor will review my information to determine the most appropriate services.

I authorize United Way of Central Alabama to contact me regarding my request.