Intake Form

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Intake Form

Things to know about your housing intake:

If you do not want to or cannot fill out the attached form, you may call 211 or 706-748-8532 and a call agent will assist you.
Answering yes or no to any question, or refusing to answer any question, does not automatically qualify or disqualify you for services; however, answering completely helps us identify the best program for your needs.
The information you provide will be shared with agencies that may be able to help. Why is it important that we share this information?

To better assess your needs and the needs of others in your community, as well as what services are available to you.
To track whether your needs, and the needs of others in your community, were actually met.
To improve the quality of care and service for homeless individuals and
families.

Completing this form is not a promise or guarantee of future housing.

What are the next steps?

Your intake will be assessed by close of business the following business day and sent to program(s) that may be able to assist you with your housing needs.
If you have provided a cell phone number, please make sure the voicemail is set up so we can leave messages for you if we can’t reach you.
You should be contacted by an agency representative by the close of business on the 3rd business day.
If you have not been contacted by an agency by the close of business on the 5th business day, please call 211 or 706-748-8532.
Calls will not be returned on weekends or holidays.

Date

YYYY

Full Name *

Date of Birth *

Last four of your Social Security Number *

Gender Preference *

Contact Phone Number

Can this phone number receive text messages?

Yes

Clear selection

Email Address

What's the best way to contact you?

What is your reported race (Check all that apply)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White/Caucasian

Do you identify as Hispanic or Latino?

Yes

Clear selection

What is your household composition? *

Couple with Children

Couple without Children

Partnered with Children

Partnered without Children

Single

Single with Children

Pregnant

Pregnant with children

Grandparent raising Children

Relative/Guardian raising Children

Other:

What is the best time of day to contact you?

Morning

Afternoon

Clear selection

If we can’t contact you by phone, where’s the best place to find you?

Emergency contact/Next of Kin Name and Contact Number

Clear form

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