General Intake Form

(For Housing Cases Use Housing Intake Questionnaire).

Note that required fields are marked with an asterisk. The form cannot be submitted unless all required fields are filled in. You may also download a printable PDF file of this form for mail submission. This file requires the free Adobe Reader. This document is also available in Arabic, French, Creole, Spanish, and SomaliPDF.

*Indicates Required Fields

Your Contact Information








(207-123-4567)
(example: 207-123-4567)
(example: 207-123-4567)

Related Contact

Name of a relative, friend or neighbor in the local area who would know how to reach you.

(207-123-4567)

Discrimination Details




Because of: *

(Employment & Credit Cases Only) (mm/dd/yyyy)
(Lodging Only-except certain B&B establishments)


( )
( )
( )
( )
( )
(This includes sexual harassment)

(Employment Only)
(Employment Only)

I Was Denied the Same Opportunity or Treated Differently From Others In (Please check all applicable.) *









(01/01/2014)

Complaint Against

I Wish to File a Complaint Against: *




If


(207-123-4567)



If Complaint Regards Employment

Currently Employed

Previously Employed

(01/01/2014)

Never employed

(01/01/2014)

Detail

To assist us in understanding the details of your situation, please provide a brief description of the reasons you believe you have been discriminated against.

(Rev. 04/14)