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Intake Form

Ready to start on your housing journey? Complete the following intake form to get started.

If speaking on the phone works better for you, give us a call at 410-366-8550.

What are you primarily looking for assistance with?(Required)

**Please note, St. Ambrose does not provide direct rent assistance (such as money for back rent), but does provide rental counseling**

Is there something additional we can assist you with?

**Please note, St. Ambrose does not provide direct rent assistance (such as money for back rent), but does provide rental counseling**

Please describe how we can assist you in a few words.(Required)

Tell us about yourself

Name(Required)

First Last

Gender(Required)

Preferred pronouns(Required)

Date of birth(Required)

MM slash DD slash YYYY

Race(Required)

American Indian or Alaska Native

Asian

Black or African American & White

Native Hawaiian or Pacific Islander

White

Other/Multi-Racial

Ethnicity(Required)

Hispanic or Latino

Not Hispanic or Latino

Are you foreign born?(Required)

Yes

No

Are you a veteran?(Required)

Yes

No

Are you active military?(Required)

Yes

No

Are you disabled?(Required)

Yes

No

Do you have a disabled dependent?(Required)

Yes

No

What is your highest level of education completed?(Required)

College

Graduate School

High School / GED

Junior College

Junior High School

None

Other

Primary

Unknown

What's the best way to contact you?

Email(Required)

Phone (mobile or home)(Required)

Are you English proficient?(Required)

Yes

No

If no, what language do you speak?

Preferred Method of Communication(Required)

Phone

Email

Other

Preferred contact time

Morning (8-10am)

Mid-day (10am-2pm)

Afternoon (2-5pm)

Anytime (8am-5pm)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

County of Residence.(Required)

Baltimore City

Baltimore County

Other

Qualifying information

Are you the head of your household?(Required)

Yes

No

What is your household type?(Required)

Female headed single parent household

Male headed single parent household

Single adult

Two or more unrelated adults

Married with children

Married without children

Other

How many people are in your household?(Required)

How many people are in your household?(Required)

Are there any non-dependents who live in your home? If yes, please list their age and relationship to you.(Required)

What is your combined monthly household income? (total monthly income of all adults 18+ who live in your home)(Required)

How did you hear about us?(Required)

Friend

Family member

Social media

Service provider referral

Outreach event

Church

Government service provider

Court referred

Radio

Other

Would you like to receive the St. Ambrose newsletter?(Required)

Yes

No

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Contact

Questions? Give us a call or contact us.

If you’re ready to get started with our programs, complete our intake form.

Phone: 410-366-8550

Fax: 410-366-8795

Address: 321 East 25^th Street

Baltimore, MD 21218

Hours: Monday through Friday

9:00 am to 5:00 pm

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