LCDC Counseling Intake
Personal Information
First Name
Middle Name
Last Name
Email
Phone Number
Is this your -
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Home Phone
Mobile Phone
Work Phone
Other Type of Phone
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Address
Street Address
City
State
Zip Code
Household and Demographic Information
Date of Birth
Month
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January
February
March
April
May
June
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September
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Day
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Year
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2025
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1932
1931
1930
1929
1928
1927
1926
Birthday Month Calc
Birthday Day Calc
Birthday Year Calc
Date of Birth
Gender
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Male
Female
Nonconforming
Race/Ethnicity
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African American/Black
Alaska Native
American Indian
Asian
Latino/Hispanic
Native Hawaiian
Pacific Islander
White
Other
Other Race Detail
Household Size (Number of people living in your home, including yourself)
Number in the household who are under 18 years of age
Annual Household Income (earned by all individuals living in of your home, including yourself)
$
Highest level of education completed
Less than High School
Two-year degree (AA)
High School Diploma or GED
Four year degree (BS, BA)
Trade, Vocational or Professional Certification
Post-Graduate Degree (Master's or Above)
N/A
Current housing status
Own
Rent
How long have you lived at your current address?
Years
Months
Monthly rent
$
per month
Purchase price of house or unit
$
Monthly mortgage payment
$
per month
Service Type
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Financial Education
Pre-Purchase
Financial Background
Place of Employment
Your Occupation
Employment Status
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Employed - Full Time
Employed - Part Time
Student - Full Time
Student - Part Time
Self-Employed
Unemployed
Do you receive public aid benefits
Yes
No
Not Sure
Do you have a budget
Yes
No
Do you have a savings and/or checking account?
Yes - Checking Account
Yes - Savings Account
Yes - Both Checking and Savings Accounts
No
Do you currently have any debt?
Yes
No
How much?
Do you currently have savings?
Yes
No
How much?
What is your Credit Score?
300 - 619
620 - 679
680 - 749
750 - 850
Don't Know
What is your Credit Score?
Combined net worth of household members, any assets owned i.e. homes, cars, boats, etc.
$
Goals
Coaching needs or reasons for engaging (e.g. rental assistance, credit building for home ownership, general credit building, opening a new savings/checking account, building savings, budgeting, debt management, etc.)
Notes/Financial Goals
Timeline to Achieve Goal(s)
Please select...
3 - 5 months
6 - 12 months
More than a year
LCDC provides the following HUD one-on-one housing counseling services: pre-purchase/homebuying; non-delinquency post-purchase; home maintenance and financial management for homeowners