Haven Legacy Living | Online Forms

Complete all applicable fields. Write N/A when a question does not apply. Share only information relevant to your housing needs. You may request a private conversation about sensitive information. Submitting this form does not reserve a room or guarantee approval or placement.

Fields marked * are required. Your answers are submitted to Haven Legacy Living’s private inbox. Call (470) 969-5900 for help.

1. Applicant & contact information

Applicant first name *

Applicant last name *

Assessment date

Applicant age

Phone number *

Email address

Emergency contact name and relationship

Emergency contact phone number

Current or last known address, city, state and ZIP

Referring agency / case manager / phone (if applicable)

Preferred housing area

Desired move-in date

2. Housing needs & daily living

Reason for seeking a new place to stay

Can you manage your daily routine?

If support is needed, please explain

Can you clean and maintain your living space?

Are you comfortable with shared living?

Can you cook or prepare meals?

Currently working, in school or participating in a program?

Describe employment, school or program participation

3. Health & support needs

Do you take prescribed medications?

Do you manage your medications independently?

Medication support or related accommodations needed (if any)

Any medical conditions relevant to housing needs?

Describe relevant needs or request a private discussion

Are you receiving mental health support?

Provider or support contact (optional)

Accessibility, mobility, dietary or other accommodation requests

4. Substance use & community safety

Current alcohol use?

Current marijuana use?

Other non-prescribed drug use?

Use of nicotine products?

Relevant substance use details or support needs (optional)

Willing to live in a drug-, alcohol- and smoke-free environment?

Current or past participation in substance use treatment?

If yes, when and where? (or request a private discussion)

Any history of violent behavior or aggression?

If yes, explain the circumstances and current safety supports

5. Shared living & personal goals

Can you follow an applicable curfew, with approved exceptions?

Can you follow visitor and overnight guest rules?

Can you participate in household chores?

Are you willing to attend meetings and check-ins?

Are you open to respectful staff feedback?

Will you bring an animal?

Animal details / support or accommodation needed

What motivates you to seek housing with Haven Legacy Living?

Short-term goals

Long-term goals

Support needed to reach your goals

6. Income, references & acknowledgment

By submitting, you send these answers to Haven Legacy Living for review and follow-up. No payment is collected here. Please do not include Social Security numbers, bank account information, or medical records.

Keep this page open until you receive confirmation.

Resident Intake Form