Hope House Assessment - PGC
This form serves as an assessment for Hope House staff to identify your needs and how we can best support you in the re-entry process. *Required
What is your Full Name
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First Name
Middle Name
Last Name
What is your date of birth?
*
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Month
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Day
Year
Date
Please list your Primary Phone Number
*
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Area Code
Phone Number
Please list your Cell Phone Number
*
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Area Code
Phone Number
Email Address
*
What gender do you identify as?
*
Female
Male
Prefer not to say
Other
What city/state do you currently reside in?
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Enter your city, state, and zip code
How long were you incarcerated?
*
What were you convicted of?
*
How long have you been released from incarceration?
*
What is your highest level of education?
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Some High School (did not finish)
High School /GED
Associates Degree
Bachelors Degree
Master Degree
Other
Do you have children? If so how many and list their ages.
*
What type of support do you need to successfully re-enter into society? check all that apply
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Housing
Employment
Education
Entrepreneurial skills training/development
Medical Services
Clothing
Food
Identification documents
Family Re-Unification
Other
What are your short term goals? (6 months - a year)
*
What are your long term goals? (2+ years)
*
Referred by:
Submit
If you have questions please contact Melaney Batiste at melaney@thelohm.org.
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