Group Home Alliance Housing Interest Form

GHA Housing Interest Form
Applicant's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
What do you identify as?*

MaleFemaleOther
Are you applying for yourself or someone else?*

MyselfSomeone Else
Do you understand this is a shared living home?*

YesNo
Have you lived in shared housing before?*

YesNo
How soon do you need housing?*
What is your current living situation?*

Living by myselfLiving with roomatesLiving with familyHomeless with no permant homeGroup Home Shared LivingOther
What type of room would you like to rent*

PrivateSemi-Private (shared room)
How long would you like to be a guest at our home?

1-3 Months1-2 years4-6 Months7-12 Months
What is your current address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duration of Occupancy
Reason(s) of leaving
How many people do you need housing for?
Funding Source*

Self-PaySocial Security Disabililty InsuranceVoucherGovt or State AssistanceSocial Security InsuranceNon-Profit Organization- Rent Assistance
What is your monthly gross income? ($)
Do you smoke?*

YesNo
We have house rules to govern the safety and harmony of the home? Would you abide by them?*

YesNo
Do you understand that no pets are allowed?

YesNo
Primary Mode of Transportation?*

Public TransportationPersonal Car
What side of town are you interested in?*

Clayton CountyGwinett CountyFulton CountyDekalb County
Have you been convicted of felony before?

YesNo
If yes, please explain below:
Are you currently taking any medications?*

YesNo
If taking medication, please list them below
Please disclose any existing medical conditions or health concerns that we should be aware of?
Do you have any food or drug allergies? If yes, please elaborate
Any important details we should be aware of, not yet addressed?
Were your referred? If so, type your referrals name in the box below.*
If you were not referred please tell us how you heard about us?*
For office use only. Name of person who filled out this application
If you are not an employee of Harbor Halo. Please leave this field blank. This is for office use only.
Upload Attachments

Cancelof
Should be Empty:

GHA Housing Interest Form