• Matrescence Ascending Housing Application

    Complete this application to be considered for our housing program. Please have your information ready and follow the prompts.

  • Person Completing This Form

  • Who is completing this application?*
  • Format: (000) 000-0000.
  • Does the applicant know you are submitting this on her behalf?

  • Preliminary Screening

  • Are you currently pregnant or within 18 months postpartum?*
  • Are you 18 years of age or older?*
  • Are you currently experiencing housing instability or currently incarcerated?*
  • Do you currently live in Georgia or are you willing to relocate to Georgia?*
  • Program Rules Summary Key expectations include: active participation in programming (parenting, financial literacy, healing garden, and case management); respecting curfew and quiet hours; a zero-tolerance policy for substances on-site; maintaining a safe and respectful home for all mothers and children; and working toward your goals with staff. You can read the full House Rules and Housing Agreement here: View the full House Rules
  • Having read the program rules above, do you agree to follow the program rules and housing agreement?*

  • Applicant Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Pregnancy/Postpartum Details

  • Current status*
  • Due date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Delivery date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Demographics & Identity

  • Gender identity*
  • Race/ethnicity

  • Family & Children

  • Do you have any children?*
  • Child details
  • Do you have close family or friends in Georgia?
  • Format: (000) 000-0000.

  • Housing Situation

  • Your safety matters to us. Are you currently in immediate danger or fleeing domestic violence?
  • Would you like us to connect you with safety resources right away?
  • What's making it hard to find or keep stable housing right now?
  • Do you have access to reliable transportation?
  • Having reliable transportation is encouraged and helps with program participation, appointments, and work — but it is not required to apply.

  • DFCS & Child Welfare

  • Do you currently have an open DFCS case?*
  • Format: (000) 000-0000.
  • Is there a court-appointed attorney?

  • Legal History

  • Are you currently incarcerated?*
  • Expected release date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently on probation or parole?*
  • Format: (000) 000-0000.
  • Do you have any pending legal matters?*

  • Employment & Financial Information

  • Employment status*
  • Benefits received

  • Health & Wellness

  • Do you currently have health insurance?*
  • Is it probation or parole?
  • When is your parole expected to end?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Will you be on probation after parole?
  • When is your probation expected to end?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Ongoing medical conditions
  • Have you ever received mental health services?*
  • Have you ever received substance use treatment?*
  • Are you currently in recovery?

  • Support Needs & Goals

  • Primary support needs*

  • Consent & Authorization

  • Authorization to Contact Providers*
  • Signature Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Would you like support connecting with substance-use or recovery resources?*
  • Thank you for reaching out. Based on your answers, our Matrescence Ascending maternity housing program may not be the right fit at this time. This program serves mothers who are 18 or older, pregnant or within 18 months postpartum, experiencing housing instability, and living in or willing to relocate to Georgia. We'd still like to help — would you like us to connect you with other resources and support?
  • Would you like us to share information about other resources that may help?
  • Should be Empty: