ILF Intake Application

Thank you for your interest in the Hurt4Healing Independent Living Facility. Please complete this application as thoroughly as possible. All information is kept confidential.

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address*

Current Address*

What is your current marital status?*

SingleCommitted RelationshipDivorced / SeparatedWidowed

What race do you identify with?*

African American / BlackWhiteHispanic / LatinoAsian / Pacific IslanderOther

Have you previously resided at Hurt4Healing House?*

YesNo

What is your highest level of education?*

Elementary SchoolMiddle SchoolHigh School / GEDTrade or Vocational ProgramBachelor's DegreeGraduate / Post-Graduate Degree

Are you currently enrolled in school?*

YesNo

Are you interested in furthering your education?*

YesNoUnsure

What is your current employment status?*

UnemployedPart-Time EmploymentFull-Time Employment

All information is kept strictly confidential.

Serving domestic violence survivors and the Georgia community with compassion, resources, and hope — 24 hours a day, 7 days a week.

770-302-0955 info@hurt4healing.org$CashApp: $hurt4healingllc

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