Gift Permanent Supportive Housing, Inc.
5536 Old National Hwy, Suite 150
College Park, GA 30349
Office #: (404) 564-6486 Fax #: (404) 564-6487
Application Date:
Time:
Full Name:
Date of Birth:
Social Security #:
Martial Status:
Gender:
Race:
Phone #:
Place of Birth:
Are you permitted to work in this county?
Are you on probation:
Are you on parole:
Are you physically/medically/mentally able to get a job?
Do you currently have a job?
If no, how do you support yourself?
Family or Friend:
Source of Income:
How much and do you have a payee?
Do you receive public Assistant?
Do you receive Food Stamps?
Do you have medical insurance coverage?
Medical Diagnosis:
Treated by:
Doctor's phone number:
Doctor's Address:
Last visit:
Current Medications:
Mental Health Diagnosis:
Date of last PPD/TB test:
Date of last RPR/Syphilis test:
Do you have a copy of your results:
Do you have your program fee to cover you monthly fee/program services?
Who will pay your program fees and there phone number::
Verified by:
Date:
Referred by (Name, Title):
Date referred:
Recommended for Treatment:
If no, specify reasons:
Date notified the referring agency:
Spoke to:
Pre-screening completed by (Name, Title):
Date and Time:
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