Pre Application Form

Stay Cozy Living Pre-Application

Thank you for your interest in the Stay Cozy Living Housing Program. Our mission is to support individuals on their path to self-sufficiency by providing a safe, positive, and supportive shared living environment.

Please note: This is a pre-application to join our waitlist and does not guarantee placement or acceptance into the program. Once we receive your completed application, a member of our team will contact you to learn more about your current situation.

At this time, we are only accepting applications from single, unaccompanied women. Unfortunately, we are unable to accommodate men, couples, individuals with pets, or families with children.

Our homes are designed for shared living arrangements, not individual units or private apartments. We appreciate your understanding and cooperation.

Eligibility Confirmation (Required): Please confirm your current living situation *

I am a single, unaccompanied female

I am accompanied by children, a spouse/partner, or pets (not eligible at this time)

I am a male (not eligible at this time)

We are continually working to expand our services and hope to accommodate a broader range of applicants in the future. If you have any questions or need further assistance, please don’t hesitate to contact us at 470-994-1965. Thank you again for considering Stay Cozy Living.

Who are you applying for? *

Please provide the name of the agency you are associated with? (If applicable) *

Representative First Name

Representative Last Name

Client First Name *

Client Last Name *

Phone *

Email *

Date of birth *

Client Gender: *

Do we have permission to leave text/message on the number provided? *

Yes

Which location are you applying for? *

Are you homeless? *

What type if housing are you or the client applying for? *

What is your sobriety date? *

What was your substance of choice? (please specify) *

Have you been clinically diagnosed with anything? (if yes, please specify) *

Have you ever been hospitalized or institutionalized for attempted suicide or having suicidal ideations? *

Yes

Are you an insulin dependent diabetic? *

Have you ever been diagnosed with bipolar disorder or schizophrenia? (select all that apply) *

Bipolar Disorder

Schizophrenia

Neither

Are you currently taking any MAT (Medically Assisted Treatment) medications? (eg. Suboxone, Sublocade, Methadone) *

Yes

Are you currently taking any "scheduled" medications? (ie. are you prescribed any narcotic medications such as Adderal, Xanax, Alprazolam, Anabolic Steroids, Ambien, etc.) If so, please list the names of medications. *

Treatment Center(s): Tell us about the most recent treatment center you've been admitted into. If you don't have all the details of the most recent treatment center you've been to, please list the name of the treatment center, what city and state it was in, your best guess of when it started and ended, the type of treatment center, and the reason for discharge. Additionally, if you are currently in a treatment center, please list the details of the current facility you are in. *

Have you ever been in a sober living house? If so, what makes this time different? *

Are you aware that this is for shared housing? *

Yes

Bedroom Interest (Pricing varies by location) *

Shared Bedroom Starting at $700

Preferred Move In Date *

Are you currently employed? *

Yes

If other, please explain

Do you/client receive SNAP (EBT) benefits? *

Yes

Do you have your own vehicle? *

Yes

Do you have a caseworker? If so, please add name and contact information. *

Do you have any known health issues that we should be aware of? *

How did you hear about us? *

Is there anything else you would like to share with us? *

Please type your full name to serve as your signature *

Date *

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