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 or men. Unfortunately, we are unable to accommodate 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

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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?

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Provide the name of the agency you are associated with? (if applicable)

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Representative First Name: Text field

Representative Last Name: Text field

Client First Name: Client first name

Client Last Name: Client last name

Phone: Client phone

Email: Client email

Date of birth: Client birthdate

Client Gender: Client gender

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

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Which location are you applng for:

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Are you currently homeless? 

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What type of housing are you or the client applying for? 

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What is your sobriety date? Date

What was your substance of choice? (please specify)

Client substances of choice

Have you been clinically diagnosed with anything?

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If yes, please specify

Client diagnosis

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

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Are you an insulin dependent diabetic?

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Have you ever been diagnosed with bipolar disorder or schizophrenia?

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(select all that apply)

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

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Are you currently taking any "scheduled" medications? (ie. are you prescribed any narcotic medications such as Adderal, Xanax, Alprazolam, Anabolic Steroids, Ambien, etc.) 

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If so, please list the names of medications.

Medication

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.

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Have you ever been in a sober living house?

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If so, what makes this time different? 

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Are you aware that this is for shared housing? 

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Bedroom Interest (Pricing varies by location) 

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Preferred Move In Date? 

Date

Are you currently employed? 

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How will you or your client pay? 

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If other, please explain:

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Do you/client receive SNAP (EBT) benefits? 

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Do you have your own vehicle? 

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Do you have a caseworker?

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If so, please add name and contact information.

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

Client medical notes

How did you hear about us?

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

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Please type your full name to serve as your signature: 

Signature

Date Date

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

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