Senior Shared Housing Pre-Screening Form
Answer a few questions to help us review eligibility for affordable shared living.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following best describes you?
*
Senior (age 55+)
Veteran
Individual with felony history
On a fixed income
Other
What is your primary source of income?
*
Please Select
Social Security
Disability Benefits
Veterans Benefits
Employment
Family Support
Other
Are you currently housed?
*
Yes
No
When are you looking to move?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please share any preferences or needs regarding shared living (optional)
Are you currently taking any prescribed medications that you would like us to be aware of in order to support your living arrangement? (Optional)
Yes
No
Prefer not to say
If yes, please list any medications or support needs you wish to share.
Do you have any mental health conditions or support needs you would like us to be aware of so we can better assist you? (Optional)
Yes
No
Prefer not to say
If yes, please share any information you feel comfortable providing.
Do you have a vehicle that will need parking?
*
Yes
No
Are you willing to relocate to wherever a room is currently available in Georgia?
*
Yes
No
Maybe
Comments about relocation or availability
House rules acknowledgment
*
I understand the home may be shared
I agree to follow house rules
I understand room assignments may change
Additional household considerations
I can live with a roommate of any gender
I can share common areas respectfully
I can adjust to community living routines
Daily Living and Support Needs
Can you live independently with the following daily activities?
*
Rows
Yes
With some help
No
Cooking
Hygiene
Medication management
Getting around
Mobility needs
*
Please Select
No mobility needs
Uses a cane or walker
Uses a wheelchair or scooter
Needs a ground-floor or accessible room
Other
Do you currently receive case management or home health services?
*
Yes
No
If yes, provider name
If yes, provider phone
Please enter a valid phone number.
Format: (000) 000-0000.
Do you need help with any of the following?
*
Food resources
Transportation
Both
Neither
Medications or allergies to keep on file for emergencies (optional)
The information you provide is kept confidential, used only to help us support residents, and does not by itself determine eligibility.
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