Gift Permanent Supportive Housing, Inc.

5536 Old National Hwy, Suite 150

College Park, GA 30349

Office #: (404) 564-6486              Fax #: (404) 564-6487

Pre-Screening Application

Martial Status:



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?

Family or Friend:

Source of Income:

Do you receive public Assistant?

Do you receive Food Stamps?

Do you have medical insurance coverage?

Do you have a copy of your results:

Do you have your program fee to cover you monthly fee/program services?

Recommended for Treatment: