Intake Referral Form

Reentry/Pre-Release Intake Referral
Please answer the following questions for birth certificate and / or identification assistance:
Location
Incarceration Date

MonthDayYear
Date
Release Date

MonthDayYear
Date
Referring Agency
Referring individual (please include name, email, and phone number)
General Intake Questions
Do you have medical (physical) health issues?
Provide description of any medical (physical) health issues
Do you have mental health issues?
Provide a description of any mental health issues
Will you have a medical or mental health provider in the community in the next 30 days?
Do you (or have you had) a substance abuse issue?
What have been your drug(s) of choice?
Have you had previous employment?
If yes, what was your last job?
Current Monthly Income
Current Housing Status
If in transitional housing, name of facility or center
If you are in transitional housing, what is the name and phone number of your case manager?
Do you have any dependent children?
If so, how many?
Are you currently on probation?
Are you currently on parole?
If so, what is the name and phone number of your parole officer?
When are you off probation or parole?
Charges
Do you have any pending charges?
If so, what are they?
Click here to input most recent charge that led to client current incarceration/release status
Have you been a victim of a crime? If so, what were the circumstances?
Needs List
List any of the needs or services you may have (with documentation, physical or mental health, clothing, food, job training, group counseling, etc.) Try to be as specific as possible
Notes
Date of Intake

MonthDayYear
Date
Intake notes
Client Name
Client Signature

Clear
Intake staff name
Intake staff signature

Clear
Date

MonthDayYear
Date
Refer to case management?

YesNo
Should be Empty:

General Intake Questions

Charges

Needs List

Notes