Client Intake Form ReEntry (ACTS)
Complete this intake form if you are nearing release and would like to enroll in our ReEntry program.
Do you have a child(ren) that is currently enrolled in other S.H.I.F.T.I.N.G Paths programs? If so, please provide their name.
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Yes
No
Child #1 Full Name
First Name
Last Name
Child #2 Full Name
First Name
Last Name
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Incarcerated Inmate Information
Full Name
*
First Name
Last Name
Sex
*
Male
Female
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
What is your email address?
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What is your inmate number?
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What is the name of your current facility?
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What are you currently incarcerated for?
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What is the name of your classification officer?
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Mr. / Mrs. / Ms.
Last Name
When is your EOS or expected release date?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upon release, will you be on probation or parole?
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Probation
Parole
Neither
Upon release, what county will you be residing in?
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Which ReEntry services would you be interested in? Select all that applies.
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Parenting Courses (if applicable)
Job Assistance Resources & Workshops
Continuing Education
Financial Literacy Education
Obtaining of Identification Documents
Government Assistance
Health & Counseling Services
Housing Referrals / Assistance
By signing below, I agree that I want to receive services from S.H.I.F.T.I.N.G. Paths, Inc. I authorize and give permission to S.H.I.F.T.I.N.G.Paths, Inc. to share information from my submitted application with GovernmentalAgencies, Non-Governmental Organizations, and with Other individuals, only to provide services, resources, and referrals on behalf of my child, or myself. I understand that the information provided will only be shared when necessary to ensure all requirements are met to receive said services.
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