Safe & Healthy Housing Assessment Request
Format: mm/dd/yyyy
Address *
Address
City
State/Province
Zip/Postal
Do you send/receive text messages? *
What is the best way to reach you? Check all that apply.
(Examples: wabbly railing, lack of working smoke detectors, problems with mold/mildew, concerns about your water, etc.)
What type of dwelling to you live in? *
Do you own this home?
Hinton Center appreciates our local volunteers. Would you like to give back? If so, our volunteer coordinator will contact you. *
Are you or is any member of your family (in the household) a veteran? *
Are you or is any member of your family disabled? *
Are you a widow(er)? *
Are you or is any member of your family (in the household) age 65 or older? *
Is anyone in your household on Medicaid?

**If yes, please visit
www.impacthealth.org/am-i-eligible/ or call
828-278-9900 to see if you’re eligible for NC’s Healthy
Opportunities Pilot (

Using your mouse, you can draw your name or click on the keyboard icon and then type your name.