Enquiry Form – abeautifullysolution.com

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First Name

Last Name

Address

Address Line 1

City

State

Zip Code

Phone number

Best time to reach you

morning

afternoon

evening

Gender

male

female

Date of Birth

Please indicate your race/ethnicity (select all that apply)

Americal Indian or Alaska Native

Asian

African American

Caucasion

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

Two or more races

Prefer not to answer

Do you identify as a member of the LGBTQ+ community?

Yes

Emergency Contact Name

Emergency Contact Phone Number

Have you ever been convicted of a crime? Please note, answering yes does not automatically disqualify you.

Yes

Do you have any criminal convictions pending? Please note, answering yes does not automatically disqualify you.

Yes

City and state of conviction:

If you answered yes to the above questions, please explain:

Do you currently have a case manager, social worker, or program contact?

Yes

If yes, please provide their name and contact info

Do you have any mental illnesses?*

Yes

If so, has this been diagnosed by a physician?

Yes

Which are you applying for?

Next Pay Date

Please note, there is a $300 one time program fee that will be due to hold your requested room. Rent is due the day of move in and will be prorated if you move in after the 1st of the month. Do you understand and agree?

Yes

By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that A beautiful solution is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.

Yes

3343 Peachtree Rd NE STE 145 Atlanta, GA 30326
1-(470)493-3955
info@abeautifullysolution.com

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