Personal Profile Intake Form Please enable JavaScript in your browser to complete this form.Note: To view the entire NeighborWorks Pocatello counseling and education fee schedule visit https://nwpocatello.org/services/education-and-counseling/.Date How did you hear about NeighborWorks Pocatello?Email *Name *FirstMiddleLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Home)Phone (Cell)Birthdate *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Race (Please Check All That Apply)WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian/Other Pacific IslanderOtherEthnicity (Please select “yes” or “no” for Hispanic Origin. You should select both a “Race” category and a “yes” or “no” for Hispanic origin.YesNoIf Yes Select OneCubanMexicanPuerto RicanSouth or Central AmericanOther Spanish CultureMarital StatusSingleMarriedDivorcedSeparatedWidowedGenderMaleFemaleDisabled?YesNoVeteranYesNoActive Military?YesNoCurrent Housing ArrangementRentHomelessHomeowner with MortgageLiving with Family Member and Not Paying RentHomeowner with Mortgage Paid OffAre you a First Time Buyer? (You do not currently own a home and have not owned a home in the past three years?)YesNoHousehold Type (please select the most accurate)Female Headed Single Parent HouseholdHomelessSingle AdultTwo or More Unrelated AdultsMarried with ChildrenMarried w/o ChildrenOtherFamily Household Size Selected Value: 0 How many dependents (Other than those listed by any co-borrower)? Selected Value: 0 What Ages are They?Are there any non-dependents who will be living in the home? (If yes, please list below)YesNoRelationship and AgeRelationship and AgeAnnual Family or Household Income:Education (Please Select One)Below High School DiplomaHigh School Diploma or EquivalentTwo Years CollegeBachelor's DegreeMaster's DegreeAbove Master's DegreeSubmit