Application

Complete your intake form.

It takes just a few minutes. All information is kept confidential.

Georgia's Best Haven Client Intake Form

Date *

Referral Source (if any)

CLIENT INFORMATION

Full Name *

Date of birth *

Age *

Gender *

Male

Female

Other

Phone *

Email *

As part of our process, we ask if any applicant is a registered sex offender. This helps us ensure we meet all safety and legal requirements *

Children if Applicable

Do you have children who will live with you? *

Yes

No

How many children ? *

How many Adults (16 years and older) *

Please enter the total number of household members who are 16 years of age or older . PLEASE NOTE Household members 16 years and older are considered adults and may affect pricing.

How many Children (15 years and under) *

Please enter the total number of household members who are 15 years of age or younger

Employment & Income

Monthly Income Amount $: *

Housing Needs

Room Typed Requested*

Shared Room ($750)

Private Room ($900+)

Move-In Date Requested *

Any mobility or accessbility needs? *

Yes

No

History & Support

Have you ever lived in shared housing before? *

Yes

No

Do you have a case manager, probation officer, or support worker? *

Yes

No

Background concerns we should be aware of (no judgement. safety only): *

Proof of identity

Please upload one (1) valid government-issued photo ID:

Driver's license
State ID Card
Passport
Military ID
Permanent Resident Card
Other Government-Issued Photo ID

Upload Valid ID

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Proof of income

Please upload proof of your current income or financial assistance.

Accepted documents include:

Recent Pay Stub (within the last 30 days)
Employment Verification Letter
Social Security/SSI/SSDI Award Letter
VA Benefits Letter
Pension or Retirement Statement
Unemployment Benefits
Child Support Documentation
Bank Statement (if applicable)
Other Proof of Income

Upload Proof of Income

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Emergency Contact

Emergency Contact: Full Name *

Emergency Contact Relationship *

Emergency Contact: Phone *

Agreements
I understand that Georgia’s Best Haven provides shared housing with house rules, expectations, and program guidelines to maintain a safe and clean environment for all residents. I agree to follow all rules and participate in the intake process honestly.

Client Signature *

Clear

Date Today *

By checking this box, I consent to receive non-marketing text messages from Georgia's Best Haven about my housing application, intake status, appointment reminders, and program updates. Message frequency varies. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including program announcements, events, and special updates, from Georgia's Best Haven at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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