Mary Ellens Hearth Housing Program

Mary Ellen's Hearth Transitional Family Housing Program

Referral and Application Form

If you need assistance filling out this application, please contact our Program Manager at 334.264.4108 or meh@embracealkids.org. You can also download the Application Form by clicking here.

This form is transmitted through a secure link to Mary Ellen’s Hearth and is received by the program administrator. It is held in confidence and only provided to others, as needed — yet in strictest confidence — and maintained that way.







Referral Information




Applicant Information



Please list last three addresses, starting with most recent: (must cover last 5 years)


List last three places of employment, starting with most recent:


Please list all current sources of income and amount:



Medical History


Do you or have you ever had problems with (please check yes or no):

Are you currently taking any medications? If so, please provide details:



PLEASE PROVIDE FULL INFORMATION FOR EACH MINOR CHILD IN THE FAMILY.




CHILD 2




CHILD 3




PLEASE READ THE STATEMENT BELOW WHICH DEFINES A “HOMELESS” PERSON AND CHECK THE REASON YOU ARE CONSIDERED HOMELESS:

I certify that I have read the specific criteria for consideration as a resident of Mary Ellen’s Hearth, and that I meet these criteria. I have checked the homeless situation above which best applies to me.

I affirm that the foregoing information is true and complete to the best of my knowledge, information and belief. I understand that this form is only an application for consideration as a participant in Mary Ellen’s Hearth’s Transitional Housing Program, and that the submission of this application does not reserve housing nor in any way guarantee acceptance into the program. I authorize verification of all information and references given.

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