HomeSource Inquiry Form

HomeSource Inquiry Form

NeighborImpact HomeSource
NeighborImpact is an equal opportunity provider and employer. If you require accommodation, please contact 541-548-2380 or reception@neighborimpact.org. If you are hearing impaired, please dial TYY 711.

NeighborImpact es un proveedor y empleador que ofrece oportunidades de igualdad. Si necesita adaptaciones, llame al 541-548-2380. Si tiene problemas de audición, marque TYY 711.
This is an initial inquiry form. Programs & Service participation will require additional documents and some may have a fee.
In what language do you prefer to receive communications? / En que idioma prefiere comunicarse?

Other
Puedes traducir este formulario utilizando el menu en la esquina superior izquierda
What is your top interest, goal, or concern? If there are more than one, you can indicate your top 3.
Do you have a secondary goal, interest or concern? If so, type your answer below.
Name

First NameLast Name
Preferred Pronoun
Date of Birth

MonthDayYear
Date
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live within Bend City Limits?
In which county/reservation do you live?

Other
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you served in any branch of the military?
How did you hear about our services?

Other
What is your current housing situation?

Other
Have you already taken one of our HomeSource workshops?
Explore our workshops on this page: https://homesource.as.me/schedule.php
Should be Empty: