Permanent Supportive Housing Program printable pdf download

Permanent Supportive Housing Program

Referral Form

Permanent Supportive Housing Program

Macon, GA 31217

Office Number- 478-803-7732

Application For Occupancy

Date Application Received:

Client I.D. :

Staff Initials:

Applicant Information

Which Housing Option are you applying for? Please check one

Shelter Plus Care w/ a preference for: First Neighborhood___ Third Neighborhood__ Bayside__

Transitional Housing (females only) __ HOPWA __ Grove Park Village__

Name (as it appear on Social Security Card):

Date of Birth:

Place of Birth:

SS#

Driver’s License No:

Driver’s License State:

Expiration Date:

Vehicle License No:

Vehicle Make/Model:

Vehicle Year/Color:

Phone:

Alternate Phone:

Email address:

Marital Status:

Spouse’s Name:

Are You a Full-Time Student?

Other Names Used in the Past:

Current Residence or Current Condition of Homelessness:

Current Address:

How long?

City

State:

Zip Code:

HUD defines a chronic homeless person as an individual who is homeless and lives in a place not meant for human

habitation, a safe haven, or in an emergency shelter; and has been homeless and living or residing in a place not meant

for human habitation, a safe haven, or in an emergency shelter continuously for at least one year OR on at least four

separate occasions in the last 3 years AND can be diagnosed with one or more of the following conditions; substance

abuse disorder, serious mental illness, or developmental disability. Does the client meet this criterion? __Yes__ No

Explain the condition of homelessness. REMINDER: Only persons coming from an emergency shelter, the street, or

places not meant for human habitation are considered eligible for Shelter Plus Care.

What resources does the client have to address their homeless situation i.e. adequate income, job, friends or relatives?

Previous Address:

How long?

City

State:

Zip Code:

Previous Residence:

Previous Address:

How long?

City

State:

Zip Code:

Employment Information

Current Employer:

Employer Address:

How long?

Phone:

E-mail:

Fax:

Permanent Supportive Housing Program

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