The Empowerment Network Application

The Empowerment Network: Another Chance Re-entry Program

Initial Assessment Application
Welcome to The Empowerment Network: Another Chance Re-entry Program! We are dedicated to providing comprehensive services and support to individuals transitioning from incarceration back into society. To better understand your needs and goals, please complete the following assessment. Your responses will help us determine which services are best suited for you.

Note: All information provided in this assessment will remain strictly confidential and only be used for program placement.
Personal Information:
Full Name

First NameLast Name
Gender
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Communication
Background Information:

The following questions will help us support you in receiving a pardon and/or certificate of good behavior. Having these documents can assist you in becoming more employable for jobs. The answers to these questions are 100% confidential and assist us in developing an individualized plan of action for your success.
Have you ever been convicted of a felony?

YesNo
Please provide the details of the felonies you have acquired below. (Offense type, Year, incarceration, length, and release date).
Are you on probation/parole?
If so, please specify the conditions, restrictions and the mandates of your parole/probation below.
Have you participated in any re-entry program before?
If yes, please provide the of the program(s) and the duration of your participation.
Goals & Supports:

In this section of the application we are trying to get to know your personal goals and aspirations. We also would like to identify the services and supports you may need from our program so we can personalize your journey with us. Please give this section some serious thought and intention. Thank you!
Briefly describe your main short term and long term goals you wish to achieve in life.
What areas do you feel you need the most support in? (Select all that apply)

Employment Assistance and Skills TrainingCPS Advocacy ProgramMentorship ProgramTeen Diversion Program (Ages 13-19)Educational/ Career PlanningHousing ServicesMental Health CounselingSubstance Abuse CounselingFamily and Relationship SupportLegal & Court Related ServicesFinancial LiteracyOther
Employment History

Please complete the fields below to the best of your ability.
Are you legally authorized to work in the United States?

YesNo
Do you need assistance obtaining documentation, such as a license, social security, birth certificate, etc.?

YesNo
If you answered yes to the above question, please specify what you need assistance with below.

Employment Details:

	Name	Position Held	How Long?	Reason for Leaving
Most Recent Employment
Previous Employment
Previous Employment
Previous Employment

Do you have any specific challenges or barriers that you anticipate facing upon re-entry? Please explain.
Are there any additional comments or information you would like to share regarding your participation in this re-entry program?
Thank you for completing the assessment! Your responses will help us tailor our services to meet your specific needs. A team member will contact you within 48 hours to discuss the next steps in your re-entry journey. If you have any urgent questions or concerns, please don't hesitate to contact us directly at (917) 991-3476 or kgalloway@10network.org

We look forward to working with you and supporting you on your path to empowerment!

Best regards,
Board President
Should be Empty:

The Empowerment Network: Another Chance Re-entry Program

Personal Information:

Background Information:

Goals & Supports:

Employment History