Bright Gate Housing Application
Please complete this form to request placement in our structured shared housing program.
Applications are reviewed within 24–48 hours.
You may also call 334-721-8311 for assistance.

First Name *

Last Name *

Gender at birth *

Female

Male

Phone *

Birthday *

Email *

Race *

Do you have children that are joining the program with you? (No Kids))) *

Emergency Contact Name *

Emergency Contact Phone Number *

Current Living Situation *

Referral Source (if applicable) *

Please list any medical history including allergies: (If none enter N/A) *

Please list any medication(s) you currently take:(If none enter N/A) *

Do you have any mental health diagnosis?

Do you have any legal restrictions that would prevent shared housing? *

Do you have any obligations with the courts *

What type of pay do you receive *

Monthly income amount (If none enter 0) *

Will you require any wheelchair-accessible features, mobility assistance, or other accommodations? *

Are you comfortable sharing common areas with other residents? *

Preferred Room Type *

Shared Room $650

Private Room $850

Do you require short-term or long-term housing? *

Long Term

Short Term

I don't know

Do you currently have or will need a home health care provider or outside support service? *

Can you live independently and manage your Activities of Daily Living (ADLs) without assistance? *

I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing. *

Yes, I understand.

No, I do not understand.

If selected for the program do you consent to fully comply with all program policies and house rules at all times? *

Yes, I will.

No, I won't

Desired move-in date *

If approved, I agree to pay a non-refundable move-in fee of $200, which covers items such as a new mattress, bed pillows, sheets, digital fingerprint setup, and administrative costs. *

Yes, I understand

No, I do not understand

Signature *

Clear

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Bright Gate Housing ApplicationPlease complete this form to request placement in our structured shared housing program.Applications are reviewed within 24–48 hours.You may also call 334-721-8311 for assistance.

Bright Gate Housing Application
Please complete this form to request placement in our structured shared housing program.
Applications are reviewed within 24–48 hours.
You may also call 334-721-8311 for assistance.