House Rules Acknowledgment

  • Intake Packet

    Please review the Intake Packet, complete your information, and sign to acknowledge agreement.

  • Intake Packet

    Please review the house rules, complete your information, and sign to acknowledge agreement.
  • Resident Intake Application
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have any children?
  • Employment Status
  • Education Level Completed
  • Do you have any disabilities or accommodations needed?
  • Do you take any medications?
  • Do you have a history of foster care?
  • Have you ever been in Extended Foster Care?

  • Release of Information (ROI)

    I, ________________________________________, authorize the SGTLC to share relevant information with:

    Name/Agency: _________________________________________
    Relationship: _________________________________________
    Phone: _______________________________________________

    Information to be shared (check all that apply):
    ☐ Housing status
    ☐ Employment progress
    ☐ Education progress
    ☐ Case management updates
    ☐ Emergency contact only
    ☐ Other: ________________________________________________

    This release is valid for:
    ☐ 6 months
    ☐ 12 months
    ☐ Until revoked in writing

    I understand I may revoke this release at any time.

     

  • I consent to participate in the Supportive Housing Program for Young Adults. I understand that: This is a temporary supportive housing program, not permanent housing. I will receive support in life skills, employment, education, and housing preparation. I am expected to participate in program activities and follow house rules. I may withdraw from the program at any time. The program may discharge me.

     

    Confidentiality & Privacy Agreement 

    Our program respects your privacy. While we are not a medical provider and not bound by full HIPAA regulations, we follow HIPAA‑aligned confidentiality standards.

    We will keep your information private except in the following situations:

    You give written permission to share information
    You are in immediate danger
    Someone else is in danger
    We are required by law to report abuse, threats, or criminal activity
    Emergency responders need information to protect your safety
    We will never share your information for marketing, sales, or non‑program purposes

     

    Video Surveillance & Monitoring 

     

    Purpose of Video Monitoring

    South Georgia Transitional Living Center uses video surveillance in certain areas of the property to help maintain safety, security, and accountability for residents, staff, and visitors.

    The purpose of video monitoring is to:

    Promote a safe living environment
    Protect residents, staff, and property
    Support incident review when necessary
    Video surveillance is not used for punishment and is not intended to invade personal privacy


    Areas Where Cameras May Be Used

    Video cameras may be in use in common and public areas, including but not limited to:

    Building entrances and exits
    Hallways
    Common living areas
    Exterior areas of the property
    Cameras are NOT placed in private areas, including:

    Bedrooms
    Bathrooms
    Changing areas

    Access to Video Footage

    Video footage is reviewed only when necessary for safety or incident review.
    Access is limited to authorized program leadership or designated staff.
    Footage may be shared with law enforcement or appropriate authorities only if required by law or for safety reasons.

    Privacy & Confidentiality

    South Georgia Transitional Living Center takes resident privacy seriously. Video footage is stored securely and retained only for a limited period of time unless needed for an active investigation or legal requirement.


    Resident Acknowledgment & Consent

    By signing below, I acknowledge that:

    I have been informed that video surveillance is used in designated common areas of the facility
    I understand the purpose of video monitoring
    I understand that cameras are not placed in private living spaces
    I understand that participation in the program requires agreement to this policy
    I voluntarily consent to video surveillance as described above as a condition of residence in the South Georgia Transitional Living Center program.

     

  • Consent to Services

  • Should be Empty: