New Participant Intake Form

As of 11/28/2021, we have 5 beds for women and 12 beds for men. We have reservation fees to cover intake fee and beds for a total of $50 due at the time of the call. $25 is the absolute minimum amount to hold the bed. We now have access to a database of metro Atlanta available units and shelters on a first come first served basis.

The purpose of this form is to assess your current situation to place you in the AHSC shelter program. We do not discriminate under any circumstances. Please be aware that although we do our best at supplying adequate shelter, we are not funded to absorb ALL financial costs associated with the program. The program is to allow you to become self-sufficient. If you have any questions or concerns, please reach us via email at info@ablehousing.org or text us at 770-415-5363.

Name

Phone

Address

City

State

Zipcode

Gender

Male Female Other

Are you pregnant?

Yes No May Be

How Many Children that will be living with you in the shelter?

Are you working?

Yes No

Are you on the bus line?

Yes No May Be

Have you been in a shelter previously?

Yes No

Do you have any critical medical conditions we need to be aware of? (Your answer will not limit you on entry into the program. We need this info so we will know how to better serve you.)

Have you had any substance abuse within the past 6 months? (If yes, please enter the name of the treatment center you attended.)

Last 4 of SSN

Date of Birth

Employer (if applicable)

Income ($ / Month )

Medicaid #

Primary Doctor Name

Primary Doctor Phone

Diagnosis

Medication(s)

Please be aware that Able Housing Services Corp is a nonprofit, tax-exempt corporation. Our programs are not completely free. We do require an entry fee on a sliding scale anywhere from $65 to $225 to be entered on https://ablehsc.org. The proceeds help us to place you when we are at capacity, it supports programs, and they are tax deductible. You are required to complete each portion of the service areas we provide. This program is to allow you to be accountable, reliable, and be self-sufficient. You agree to meet with the case manager weekly via text, call, chat, or virtually. You are expected to complete tasks in the area of shelter, food, transportation, health and nutrition, work-related activities, education/training, and/or disaster assistance. If you agree, please type your name as it relates to the expectations of the organization and the program.

I agree to Participant Acknowledgment

1. We do Assessment/Intake.
2. We check for availability and collect entry fee on https://ablehsc.org. Click the Donate tab.
3. Move into temporary housing.
4. Complete the weekly tasks that consist of ANY of the program areas: Housing, Finance, Food, Health and Wellness, Education, Work, Transportation, Disaster Assistance. You complete tasks by reaching out and discussing what you’ve done. You must do this for at least 30 days and make progress. Upon availability, you will go to the next step.
5. Move into transitional housing and continue to work on specific program tasks and complete assessment with case manager.
6. Prepare for long term housing and complete another assessment.
7. Graduate and prepare for your apartment or rental house. You will receive great gifts to help you in your first month.

The program may be altered and discussed with each participant as needed. We will work hand in hand to ensure you are on the right track. Our goal is to ensure your success and your path to self-sufficiency. We require a minimum of $65 to enter the program. This helps with the programming of the shelter and the funds are tax-exempt.

All shelter vacancies are based on availability.

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Participant Acknowledgment