Intake Form

Candidate Intake Form

All You Need Is A Fresh Start
Butterfly Village Independent Housing Program
Where Safe Housing Inspires New Beginnings.

Butterfly Village Independent Housing Program provides structured independent housing for adults ages 35 and older experiencing chronic homelessness (6 months or more) in the Atlanta Metro area.

Our program offers a safe, furnished home and supportive services to help residents transition toward permanent housing and independent living.

Eligibility:
- Single adults (35+)
- Homeless for 6 months or longer
- Able to live independently
- Motivated to achieve stable housing
Residents Must Be Able To:
- Prepare meals and care for themselves
- Manage medications independently
- Maintain personal hygiene
- Travel safely in the community
- Follow house rules and participate in the program
Please Note: Butterfly Village Independent Housing Program does not provide 24-hour supervision, personal care, nursing services, medication administration, or medical/behavioral health treatment.

We welcome referrals from hospitals, behavioral health providers, homeless service agencies, social workers, veteran organizations, faith-based organizations, and other community partners.
Thank you for your interest in the Butterfly Village Independent Housing Program.

This program provides safe, structured, independent housing for single adults ages 35 and older who have experienced homelessness for six months or longer and are working toward permanent housing.

Please complete the information below. Completing this form does not guarantee placement. Eligible applicants will be contacted for an assessment interview.
Application Information
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How do you prefer to be contacted?
Section 2: Housing Status
How long have you been homeless?
Click one
Where are you currently staying?
Check one
If "other", please list here.
Are you currently working with a Case Manager?
Case Manager Name

First NameLast Name
Agency
Case Manager Email
example@example.com
Case Manager Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Notes
Section 3: Program Eligibility
Are you at least 35 years old?
Can you safely live independently without 24-hour supervision?
Are you able to: (Check ALL that applies)
Section 4: Income & Employment
Current Income Source?

Other
If "other", please provide income means.
Income amount? (approximate)
Type dollar amount
Are you currently working?
Section 5: Supportive Services
Do you currently receive any of the folowing?

Other
If "other", please provide
Are you interested in:
Check One
Section 6: Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Section 7: Program Expectations
Please acknowledge the following:
Section 8: Additional Information
Is there anything you would like us to know about your housing needs or goals?
Section 9: Consent

Please sign electronically below.
Signature
Should be Empty:

Candidate Intake Form

Application Information

Section 2: Housing Status

Section 3: Program Eligibility

Section 4: Income & Employment

Section 5: Supportive Services

Section 6: Emergency Contact

Section 7: Program Expectations

Section 8: Additional Information

Section 9: Consent