The Jack Brewer Foundation’s
Post Release Application
Participant Application
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Location
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SS Number (Last 4 Digits)
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone
Please enter a valid phone number.
Are you a Veteran?
Yes
No
If so, which branch?
Have you lived in a recovery residence before?
Yes
No
Where do you live now (Legal Address)?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your source of income?
Please Select
W-2
Self Employed
SSI
VA
Disability Income
Eligibility #?
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Are you currently, or will you upon release, be considered the biological, custodial, legal, adoptive, foster, stepfather, grandfather, non-relative male, or male family member serving in a father role of a child or children 17 y/o or younger in the state of Florida?
Yes
No
Did you grow up with an active father?
Yes
No
Marital Status:
Married
Single
Divorced
Number of Children (Stepchildren, grandchildren, nieces, nephews, or non-related children that you will have a significant impact their lives upon release):
Were you convicted of a crime as a youthful offender (Charged with a crime before the age of 21)?
Yes
No
Have you been arrested for a sex crime or Arson ?
Yes
No
Number of criminal justice impacted family members:
Are you in contact with your children?
Yes
No
Do you want to be in contact with you children?
Yes
No
Who do the children reside with currently?
Name/Relationship?
Current Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Probation/Parole?
Yes
No
Start Date
-
Month
-
Day
Year
Probation/Parole
End Date
-
Month
-
Day
Year
Probation/Parole
P.O. Name
P.O. Phone Number
Please enter a valid phone number.
Court case/Charges pending?
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Are there any restrictions regarding guardianship/visitation?
Yes
No
If yes, please explain.
Enrolled in college/University?
Yes
No
Days in Attendance :
Do you have an open child support case?
Yes
No
Unsure
Family/Emergency Contact
Family Contact Name
Phone
Please enter a valid phone number.
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone
Please enter a valid phone number.
Receive SSI or SSDI?
Yes
No
Medical Issues?
Yes
No
Brief the Medical Issues
Current Medications
Age of first used drugs
Drug(s) of choice
Date of last use
-
Month
-
Day
Year
# of relapses in a year
Treatment Program Completed
Yes
No
How many?
If so which one?
Addictions of compulsive behaviours you have:
What kind of problems has drinking and/or drug use caused you?
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Have you ever received a DUI?
Yes
No
How many?
Do you have problems with rules/authority?
Are you prejudiced towards any groups or race?
Have you ever experience suicidal thoughts?
Yes
No
If yes, how long ago?
Are you currently experiencing any suicidal thoughts?
Yes
No
If yes, have you thought of a plan?
Yes
No
If you answered yes to the previous suicide questions, do you agree to enter into a plan of action/safety if needed?
Yes
No
Currently employed?
Yes
No
Name of Company
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name
Supervisor's Phone Number
Please enter a valid phone number.
Frequency of contact with family?
Daily
Weekly
Bi-weekly
Monthly
Yearly
Do you currently receive visits from your family?
Yes
No
If so, please explain:
Family Visits
Does your immediate family currently receive government assistance?
SNAP
Medicaid
TANF
Other
Does your immediate family need additional assistance with food, clothing, or shelter?
Yes
No
Unsure
Do you feel your immediate family would participate in parenting class and other family focused development programs?
Yes
No
Unsure
Are you Currently enrolled in Continuum of Care (COC) Programming?
Yes
No
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Education Level
High School
College
GED (completed or currently enrolled)
Professional Skills/Certifications/ Licenses
Have any of your children or family members been incarcerated?
Yes
No
If yes, How many of your family members have been impacted by the criminal justice system?
Felony convictions?
Yes
No
What?
Felony convictions
When?
Felony convictions
Where?
Felony convictions
Do you own a car?
Yes
No
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STAFF USE ONLY
Applicant Accepted
Yes
No
Date of Intake
-
Month
-
Day
Year
Date
Move-in-Date
-
Month
-
Day
Year
Date
Move In Location, Housing Sponsor
Participant Signature
Date
-
Month
-
Day
Year
Staff Signature
Date
-
Month
-
Day
Year
Submit
Should be Empty: