Intake form - ReEntry

Your name (person filling out the form). *

Your Email Address *

Phone number *

Preferred method of contact:

Please select at least one option.

Phone

E-mail

Text Messaging

Are you contacting us for yourself or someone else? *

Please select at least one option.

Myself

Friend or Family Member

Client

If you are contacting us for someone else, what is their name?

Which services are you requesting? *

Please select at least one option.

Job training

Life skills workshops

Expungements

Housing Assistance

Other

Do you currently have any open supervision or court obligations?

Please select at least one option.

Yes, probation/parole

Yes, pending case

No

Unsure

Is this pursuant to a Court Order (e.g. probation requirement?) *

Please select at least one option.

Yes

No

If you are reaching out pursuant to a court order, please provide the trial court case number.

Please describe your current housing situation.

Please select at least one option.

Rent

Own

Living with family

Homeless

Other

Do you currently pay more than 30% of your monthly income toward housing costs?

Please select at least one option.

Yes

No

Unsure

Have you previously participated in any reentry programs? *

Please select at least one option.

Yes

No

If so, what program and with whom?

Are you working with any attorneys, social workers, or case managers? (check all that apply) *

Please select at least one option.

Attorney

Social Worker

Case Manager

None

What skills or training are you interested in developing? (check all that apply) *

Please select at least one option.

Technical skills

Communication skills

Financial literacy

Coping strategies

Job search skills

Reading Comprehension

Writing Skills

Other

Have any barriers affected or hindered the reentry process? (check all that apply) *

Please select at least one option.

None

Transportation issues

Prior Evictions

Outstanding fines and/or court costs

Access to computers

Childcare obligations

History of trauma

Sex offender designation

Lack of identification or other documents

Other

What is the highest level of education completed? *

What is your current monthly household income? ($0–$1,000 / $1,001–$2,000 / $2,001–$3,000 / $3,001+)

Do you currently receive any public assistance? (Check all the apply)

Please select at least one option.

SNAP

Medicaid

TANF

SSI

SSDI

Housing Assistance

None

Primary goals in PCP’s Reentry Projects? *

How did you hear about us? *

If we can't help you, we'll find someone who can. Please identify any other issues or matters you may require assistance with. (check all that apply)

Please select at least one option.

Record Sealing

Probation Modification/Termination

Restoration of Voting Rights

Housing Placement

ESOL

Immigration

Substance Abuse Counseling

Mental Health Counseling

Clemency

Mugshot Removal

Ink Removal

Drivers License Reinstatement

Parental Rights/Visitation

Post Conviction Project Inc.