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Home
About Us
Volunteer/Job Opportunities
Admissions
- Admissions Application
Sponsors & Partners
Donate
Upcoming Classes
Events

Home
About Us
Volunteer/Job Opportunities
Admissions
- Admissions Application
Sponsors & Partners
Donate
Upcoming Classes
Events

Intake Assessment Form

Genesis Joy House / Intake Assessment Form

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Admissions

(Entry eligibility could take up to one week)
Genesis JOY House Homeless Shelter, Inc.
PO Box 6425, Warner Robins, GA 31095
(478) 236-2207

Identifying Information

*Applicant Last Name

*First Name

Middle Initial

Email

*Street Address

*City, State, ZIP

*ZIP of Last Address

*How Long at previous address?

*County of origin prior to entering program

*Phone Number

*Social Security Number

*Date of Birth

*Place of Birth

*State ID or Driver's License?

Yes

No

License or ID Number

Expiration Date

*Gender

*Race

If Other or Multi-Racial, please specify

*Ethnicity

*Applicant's Primary Language

Secondary Language if applicable

*Relationship Status

If Other, please specify

*Are you presently in a relationship?

Yes

No

Military Discharge Status

*Are you a veteran?

Yes

No

*Honorable Discharge?

Yes

No

*Dishonorable Discharge?

Yes

No

*DD214 received?

Yes

No

Discharge Code

If dishonorable discharge, state reason(s):

Emergency Contact

*Emergency Contact Name

*Emergency Phone Number

*Emergency Complete Address (Street, City, State, ZIP)

Prior Living Situation

*Have you been homeless off and on or consistently in the past:

Yes

No

*2 years?

Yes

No

*3 years?

Yes

No

If so, why?

*In the past thirty (30) days, what has been your living situation?

If Other, please specify

Location Address (Street, City, State, ZIP)

Notes

*Do you feel like harming yourself or others?

Yes

No

Notes

Criminal Background

*Have you ever been convicted of a crime?

Yes

No

*Are you currently on probation or parole?

Yes

No

If yes, what was/were your charge(s)

Reporting Status/Probation or Parole

County/State

Probation/Parole Officer’s name

Amount of fines, if applicable

PO’s phone number

Email address

Pending court date(s)

Signature

By typing my name, I agree that I have answered all questions truthfully.

*Applicant's Signature

*Authorized Signature

*Date

About Us

Genesis Joy House Homeless Shelter, Inc., is a 501(c)(3) nonprofit organization committed to ending chronic homelessness among women veterans in the Southeast.

Call us:
(478) 236-2207

Email: Click here to email

Address:
501 Marshall Ave.
Warner Robins, GA 31093

Mailing Address:
PO Box 6425
Warner Robins, GA 31095

Proud Member

Genesis Joy House Homeless Shelter, Inc. is a proud member of:

Text To Give

Our Giving Club offers a convenient and easy way to donate. Every dollar you give ensures that the most urgent needs of our homeless female veterans are met.