Gift Permanent Supportive Housing, Inc.
5536 Old National Hwy, Suite 150
College Park, GA 30349
Office #: (404) 564-6486 Fax #: (404) 564-6487
Date of Birth:
Social Security #:
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?
Doctor's phone number:
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::
Referred by (Name, Title):
Recommended for Treatment:
If no, specify reasons:
Date notified the referring agency:
Pre-screening completed by (Name, Title):
Date and Time:
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