WNY House Mentor

Open House Prospect Card

Please complete this quick form so we can follow up with you.

event
Saturday, March 14 · Private & Shared Rooms — Utilities . Wi-Fi & Premium amenities included
Step 1 of 3 — Contact
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person
Section A — Everyone
Basic Contact
1
Full Name *
Please enter your full name
2
Phone Number *
Please enter your phone number
3
Email Address *
Please enter a valid email address
category
Section B — Everyone
What Brings You Here?
4
Please select what best describes you *
I'm here to support the event Supporter
I'm looking for housing Housing Seeker
I'm a case manager / social worker making referrals Referral
Please select an option

⚡ Smart form: Your next questions will automatically adjust based on your selection above.

✦ Case Manager / Social Worker
work
Section C — Case Managers Only
Referral Information
5a
Organization / Agency Name
5b
How many clients are you currently seeking housing for?
5c
What type of housing do your clients typically need?
✓
Private room in shared home
✓
Shared room
✓
Apartment / House
✓
Not sure yet
✦ Housing Seeker Questions
home
Section D — Housing Seekers Only
Housing Interest
6
What type of housing are you seeking?
✓
Private room in shared home
✓
Shared room
✓
Apartment / House
✓
Not sure yet
7
Desired Move-In Date
9
Comfortable in shared community home?
8
Budget Range (monthly rent)
$800 – $950
$950 – $1,200
$1,200 – $1,500
$1,500 – $2,000
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Section E — Everyone Completes
Final Questions
10
How did you hear about WNY House Mentor?
✓
Facebook
✓
Instagram
✓
WNY House Mentor (direct)
✓
Other
11
Any questions or comments for us?

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