GHA Housing Interest Form
Applicant's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
What do you identify as?
*
Male
Female
Other
Are you applying for yourself or someone else?
*
Myself
Someone Else
Do you understand this is a shared living home?
*
Yes
No
Have you lived in shared housing before?
*
Yes
No
How soon do you need housing?
*
What is your current living situation?
*
Living by myself
Living with roomates
Living with family
Homeless with no permant home
Group Home Shared Living
Other
What type of room would you like to rent
*
Private
Semi-Private (shared room)
How long would you like to be a guest at our home?
1-3 Months
1-2 years
4-6 Months
7-12 Months
What is your current address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Duration of Occupancy
Reason(s) of leaving
How many people do you need housing for?
Funding
⚠️ Note: If you report $0 income, we may only be able to refer you to outside emergency resources such as 211 or local shelters. Most transitional housing programs require some form of consistent income to qualify. This helps ensure stable placement and ongoing support.
Funding Source
*
Self-Pay
Social Security Disabililty Insurance
Voucher
Govt or State Assistance
Social Security Insurance
Non-Profit Organization- Rent Assistance
What is your monthly gross income? ($)
Do you smoke?
*
Yes
No
We have house rules to govern the safety and harmony of the home? Would you abide by them?
*
Yes
No
Do you understand that no pets are allowed?
Yes
No
Primary Mode of Transportation?
*
Public Transportation
Personal Car
What side of town are you interested in?
*
Clayton County
Gwinett County
Fulton County
Dekalb County
Have you been convicted of felony before?
Yes
No
If yes, please explain below:
Are you currently taking any medications?
*
Yes
No
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.
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