LOPATL Housing Application

Living On Purpose ATL, Inc. 1055 Howell Mill Rd. Atlanta, GA 30314 Phone: 678-653-1771 Email: lopatl2020@gmail.com Website: lopatl.org
Housing Application
Date*

MonthDayYear
Date
Full Name of Applicant and Nickname/Alias*
Section 1
Application being completed on behalf of:*

SelfSomeone else
If someone else, what is your relationship to the individual?
Email*
example@example.com
Phone*
Is this a cell phone?*

YesNo
Section 2

Currently Incarcerated Inmates
Complete this section ONLY if the individual seeking housing is currently incarcerated.
Are you or the person you're filing for currently incarcerated?

YesNo
Facility where incarcerated?
GDC#
Expected date of release?

MonthDayYear
Date
Counselor's name
Counselor's phone
Counselor's email
example@example.com
How many times have you (or they) been incarcerated before:

One time2 or 3 timesMore than 3 times
Do you have a history of drug use?

YesNo
If yes, do you have a history of relapsing or testing positive for drug use?

YesNo
Will you be on probation or parole upon release?

YesNo
If yes, what is the name of the PO?
Probation/Parole Officer #
Ex: 555-555-5555
Probation/Parole Officer
example@example.com
If yes, what will be the conditions of the probation or parole?
Will you be required to register as a sex offender?

YesNo
If currently incarcerated and on prescribed medications, will you be released with a supply of medications?

YesNo
If so, how many days of supplies?

1-3 days14 days30+ days
If currently incarcerated, what are your short term (6 month to 1 year) goals once release?
Section 3

Individual Seeking Housing
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Social Security Number*
Do you have a valid state ID?*

YesNo
State of Issue
ID#
Do you have a birth certificate?*

YesNo
Are you married?*

YesNo
Do you have children under the age of 18 that you will be the primary caregiver for?*

YesNo
If yes, will you be ordered to pay child support?

YesNo
Race/Ethnicity*

Black/African AmericanWhite/CaucasianAsianAlaskan NativeNative/Indian AmericanPacific Islander/Hawaiian NativeOther/Multicultural
Are you required to register as a sex offender?*

YesNo
If yes, are there limitations on where you can live?

YesNo
If yes, what are the limitations?
Please list ALL current health conditions:*
Do you have to take medications for any of these conditions?*

YesNo
If yes, please list the medications you take:
Have you received the COVID19 Vaccine? (both doses)*

YesNo
If yes, when did you receive your vaccine?
Have you currently or in the past been diagnosed with a mental health issue or disorder?*

YesNo
If so, what is that condition?
Medications taken for that condition:
Previous history of drug or alcohol addiction?*

YesNo
If yes, which type and how long have you been clean?
Do you require the aid of physical accessibility supports?*

YesNo
If yes, which type?

CaneWalkerWheelchairWheelchair RampOther
Do you have any physical limitations that will keep you from walking to the nearest bus stop?*

YesNo
Section 4

Personality and Character
Although living preferences cannot be guaranteed, we ask that you be honest in order to help staff better place you in the event you are accepted.
On a scale of 1 to 10, how would you rate your level of cleanliness?*
On a scale of 1 to 10, how coachable do you consider yourself to be?*
Do you identify as LGBTQIA+?*

YesNo
If yes, are you transgender?

YesNo
Are you comfortable sharing space with others who are not of your same race and ethnicity?*

YesNo
Are you comfortable sharing space with others who are not of your same religion or faith?*

YesNo
Are you comfortable sharing space with others who are not of your same religion or faith?*

YesNo
Are you comfortable sharing space with others who are gay or lesbian?*

YesNo
Do you prefer to share a room with someone who is:*

Younger than 2526-3536-5050+
Do you consider yourself to be a team player?*

YesNo
Why were you incarcerated?*
How long were you incarcerated?*
Section 5

Income, Education, & Employability
Are you currently employed?*

YesNo
If yes, where and what are the hours you work?
If no, are your actively seeking employment?

YesNo
If no, do you need assistance?

YesNo
Do you receive social security or disability?*

YesNo
If yes, how much do you receive each month?
What is your highest level of education?*

Middle School (6th-8th Grade)High School (9th-12th Grade)Certificate/Trade SchoolSome CollegeAssociate's DegreeBachelor's DegreeMaster's Degree or high
If middle school or high school, what is the last grade you completed?
If you received one or more certificates or degrees, what are they in?
What special skills do you have?
What are your long term goals? (1-3 years)*
Please list 2 or more emergency contacts
Emergency Contact 1:*

First NameLast Name
Phone*
Type:*

HomeCellWork
Email*
example@example.com
Emergency Contact 2:*

First NameLast Name
Phone*
Type:*

HomeCellWork
Email*
example@example.com
Emergency Contact 3:

First NameLast Name
Phone
Type:

HomeCellWork
Email
example@example.com
Why do you think you should be accepted into Living On Purpose ATL's housing program?*
By signing this application, I attest that everything I have listed above is true and accurate to the best of my knowledge. I also that submission of this application does not mean that I have been accepted into any Living On Purpose ATL programs. I also understand that if I am accepted into the program, I attest to my willingness to abide by all program rules set in place by Living On Purpose ATL and understand that any violations of program rules could result in my stay at the program being
Printed Name of Individual Seeking Housing with Living On Purpose ATL*
Signature of Individual Seeking Housing with Living On Purpose ATL

Clear
Date

MonthDayYear
Date
If applying on behalf of individual
Printed Name of Individual Applying on Behalf of Applicant Seeking Housing with Living On Purpose ATL
Signature of Individual Applying on Behalf of Applicant Seeking Housing with Living On Purpose ATL

Clear
Date

MonthDayYear
Date

Housing Application

Section 1

Section 2

Section 3

Section 4

Section 5

Please list 2 or more emergency contacts

If applying on behalf of individual

DO NOT WRITE BELOW THIS LINE