Today’s Date
First Name Last Name DOC# Release Date Email address Address upon release (if known) Primary Telephone Number upon release (if known) Message Telephone Number upon release Message Contact Name
Date of Birth Age
Race (select all that apply) AsianBlack or African AmericanHispanicWhite or CaucasianPacific IslanderNative American Indian or Alaskan NativeOther
Primary Language Spoken Is English a second language for you? YesNo
Gender? MaleFemaleTransgender
Marital Status SingleLegally SeparatedMarriedDivorcedWidowedIn a Relationship
Parenting Status Not a parentSingle ParentMother/Father Parent or Joint CustodyNon-Custodial ParentGrandparent raising grandkidsCaregiver/Foster Parent
Relationship to Children Fatherbiological/adoptive/foster/stepMotherbiological/adoptive/foster/stepGrandparentOther relative or non-relative
Are you responsible for child support? YesNo
If yes, how many cases
In what states
Do you have a copy of your order? YesNo
Do you currently have a child custody or DCS case?Child custodyDCSNone
Are you a Veteran of the U.S. Military?YesNo
Most likely housing upon release Halfway House Name of Halfway House:
Rehab Program Name of Program
Renting My Own HousingIn Housing I OwnWith Family/FriendsHomelessShelterMRC ProgramSection 8 HousingPublic HousingOther Name Other
What will be your sources of financial income upon release?Employment Name of Company Self-EmploymentUnemploymentOdd JobsDisability BenefitsNoneOther Name Other
EMPLOYMENT HISTORY Have you ever been employed?YesNo What job / career do you want to have when you release?
Highest Level of Education Grade SchoolSome High SchoolHS DiplomaGEDTechnical or Trade CertificationSome CollegeAssociates DegreeBachelor's DegreeMaster's DegreeDoctoral Degree Last grade completed
Future Education Goals Do you have anything that gets in the way of successful learning, such as a skill deficit or learning disability?YesNo
If yes, please describe
How would you rate your health?PoorFairGoodExcellent
Explanation Does a disability impact your daily living?YesNo If yes, please describe Have you seen a doctor while incarcerated?YesNo Have you seen an eye doctor while incarcerated?YesNo Have you seen a dentist while incarcerated? YesNo Are you currently taking any prescription medications? YesNo Do you require glasses to read, work, etc.? YesNo Have you ever been matched with a mentor before? YesNo Have you ever experienced any of the following? Alcohol AbuseYesNo Drug AbuseYesNo Self-MutilationYesNo Attempted SuicideYesNo Assistance Needed (What services can we help you with?) EducationClothingFood box or Food ReferralsFamily LawChild SupportHygiene ItemsApplication Assistance (Food Stamps, Cash Assistance, AHCCCs)Referral to physical health examReferral to mental health counselingReferral to substance use counselingDental ReferralsFurniture ReferralsHousing ReferralsHome Buying ReferralsSober Living/Halfway House ReferralParenting Education Classes/WorkshopFinancial EducationEyeglasses Prescription and/or Eye Glasses VoucherBeing matched to a Mentor
