The Bailout Project
Today's Date:
*
/
Month
/
Day
Year
Date
Date of Assessment:
*
/
Month
/
Day
Year
Date
Name
*
Client First Name
Client Last Name
Holding Facility
*
Fulton (Rice Street)
Atlanta
DeKalb
Booking Number:
*
Housing Location/Pod:
Bond Amount:
*
Age:
*
Race:
Gender:
Date of Arrest:
*
/
Month
/
Day
Year
Date
Attorney Name:
*
Staff Attorney Contact Information
Attorney's Cell Phone:
*
Attorney's Office Phone No.
*
Email:
*
example@example.com
Other Information
*** Attorney
should not
be listed as community tie contacts ***
Community Tie Contact Name:
*
Community Tie Phone Number
*
-
Area Code
Phone Number
Community Tie Relationship to client:
*
Second Community Tie Contact Name:
*
Second Community Tie Relationship to client:
*
Second Community Tie Phone
*
-
Area Code
Phone Number
Charges:
*
Needs Assessment
Permanent Address:
*
Release Day Address:
*
Year(s) at permanent address
*
Month(s) at permanent address
*
With whom do you live?
*
Highest level of Education?
*
Last place of employment?
*
Prior arrests and/or convictions? Y N
*
Yes
No
If "Yes," above please list convictions.
Are you in school
*
Yes
No
N/A
Other
Do you need education assistance?
*
Yes
No
N/A
Other
Do you have children or dependents?
*
Yes
No
N/A
Other
Do you need help with parenting classes or resources?
*
Yes
No
N/A
Other
Do have a valid ID?
*
Yes
No
N/A
Other
Do you need help getting a valid ID?
*
Yes
No
N/A
Other
Do you have a cell phone?
*
Yes
No
N/A
If "Yes", above please provide cell number and carrier
Do you need help finding stable housing?
*
Yes
No
N/A
Other
Are you employed?
*
Yes
No
N/A
Other
Do you need help finding stable employment?
*
Yes
No
N/A
Desired Employment Type:
Do you need any substance abuse assistance?
*
Yes
No
N/A
Other
Have you been diagnosed with any mental or behavioral disorders
*
Yes
No
N/A
Other
Do you need behavioral health treatment?
*
Yes
No
N/A
Other
If you need behavioral health treatment will you consent to speaking with a social worker?
*
Yes
No
N/A
Other
Have you already been accepted into any outside programs or treatment facilities through your lawyer?
*
Yes
No
N/A
Other
Would you be willing to stay in touch with us throughout this process, at least until your case is resolved, as part of the TLP 404 Bail Out Project? We will provide you with someone who will keep in touch with you.
*
Yes
No
N/A
Other
Do you understand that we cannot control the requirements of your bond/release but will do what we can to make compliance easier for you?
*
Yes
No
N/A
Other
If you are 25 or younger, would you be willing to work with the Next Level Academy upon your release for mentorship opportunities?
*
Yes
No
N/A
Other
Would you like for us to keep in touch with your attorney until your case is resolved?
*
Yes
No
N/A
Other
Do you understand that you will be responsible for providing accurate contact information to the court and any bonding company if you are released?
*
Yes
No
N/A
Other
If selected for our bailout initiative, do you consent to being photographed and/or filmed for The Love Project 404 marketing purposes?
*
Yes
No
N/A
Other
Please identify what you believe is the nominee's most pressing critical needs are:
Please share why you recommend this client for this initiative or anything else you'd like us to know:
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