LVDLUP RE-ENTRY Intake Form

LVDLUP RE-ENTRY

INTAKE FORM
PARTICIPANT INFORMATION
Intake Date*

MonthDayYear
Date
Referral Source*
Participants First Name*
MI*
Last Name*
Eligibility Have you recently exited or are in the process of exiting incarceration within the past 36 months?*

YesNo
Have you ever been incarcerated?*

YesNo
Date of release

MonthDayYear
Date
Are you in work release?*

YesNo
Anticipated ERD
Participants DOC/BOP Number
Address *
Phone*
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Do you identify as LGBTQI*

YesNoOther
Gender*

MaleFemaleSelf-Describe
US Citizen*

YesNo
Preferred language to receive services*
Considered Disabled*

YesNo
Experiencing Homelessness*

YesNo
Military Veteran*

YesNo
Race*

African AmericanLatinoNative AmericanWhiteAsian AmericanOther
Single Parent*

YesNo
Source of Benefits*

TANFGAUHENSSISSDIRCASNAP
Emergency Contact Name*
Phone*
HEALTH
Do you have healthcare insurance?*

YesNo
Do you need assistance getting healthcare insurance?*

YesNo
LEGAL INFORMATION
Do you have any current legal issues?*

YesNoRefuse/Unknown
If yes what are they
Charge
Year
MisdemeanorFelonyViolent
Charge
Year
MisdemeanorFelonyViolent
Charge
Year
MisdemeanorFelonyViolent
Charge
Year
MisdemeanorFelonyViolent
Charge
Year
MisdemeanorFelonyViolent
Were you convicted of a sex offense?*

YesNoRefuse/Unknown
Are you required to register as a sex offender?*

IIIIIIDoes not apply to me
Are you currently on probation/parole?*

YesNoRefuse/Unknown
If yes who is your community correctional officer
Do you have any LFO's amount?*

YesNo
Amount
Current Drivers License?*

YesNoSuspended or Revoked
WORK HISTORY
Are you currently working*
Current or Last Job*
Monthly salary*
EDUCATION HISTORY
High School Name*
Other Courses or Certifications
REENTRY ACTION PLAN

What would you like to accomplish during these phases of REENTRY?
Job Search*

YesNo
Support groups*

YesNo
Basic Computer Skills*

YesNo
Peer Groups*

YesNo
GED*

YesNo
Spiritual religious groups*

YesNo
Housing*

YesNo
Therapy*

YesNo
Peer mentoring*

YesNo
Financial counseling*

YesNo
Resume building*

YesNo
Business coaching*

YesNo
Interview skills*

YesNo
Family reunification*

YesNo
Training options or vocational skills training*

YesNo
Other explain
HOUSING
Type of housing?*

TransitionalRentOwnShelterOtherType DOC housing vochure
How are you paying for housing*
Are you faced with any challenges or barriers of living at this residence*
What is your plan of action to overcome these challenges or barriers
What resources do you need to succeed with this plan*
FORMS OF IDENTIFICATION
What forms of identification will you have while transitioning?
State ID*

YesNo
Birth Certificate*

YesNo
Immigration ID*

YesNo
Military ID*

YesNo
Social Security card*

YesNo
Veteran ID*

YesNo
Prison ID*

YesNo
Tribal ID*

YesNo
RELEASE OF INFORMATION
I,Name* First Name Last Name hereby authorize the release of my information to the following:
I. EMPLOYERS

Employers are authorized and requested to share information with Leveled Up REENTRY staff regarding my employment, including such items as start date, wages, and issues that are impacting or have impacted my continued employment or ability to progress to a higher wage or position.

II. TRAINING/EDUCATIONAL INSTITUTES

Training/educational institutions are requested and authorized to share information with Leveled Up REENTRY staff regarding my participation/progress in school, student ID numbers, financial aid status, and certifications.

III.WASHINGTON STATE EMPLOYMENT SECURITY

Employment Security is requested and authorized to release information to Leveled Up REENTRY staff regarding employment, Unemployment Insurance claim history, and wage history. I also authorize Employment Security to share information in WorkSourceWA with Leveled Up REENTRY staff.

IV. DEPARTMENT OF SOCIAL AND HEALTH SERVICES

I consent to the use of confidential information about me within DSHS to plan, provide, and coordinate services,treatment, payments, and benefits for me or for other purposes authorized by law. I further grant permission to DSHS and Leveled Up REENTRY to use my confidential information and disclose it to each other for these purposes. Information may be shared verbally or by computer data transfer, mail, or hand delivery. I understand that upon receipt of this information by Leveled Up REENTRY, it will be held in the strictest of confidence and will not be released without my written permission to anyone except funding sources for the program. This authorization shall be in effect for three (3) years from the date of signature.

I understand that by signing this release of information form, I am authorizing the disclosure of my information as described above. I acknowledge that this authorization is voluntary and can be revoked at any time by providing written notice to the recipient. I consent this information will be held in the most confidential manner and not release without written permission to anyone except funding sources for Leveled Up Reentry. This authorization shall be in effect for 3 years from the date of signature.
I, Name First Name Last Name hereby authorize the release of my pictures, videos, and data to: Leveled Up REENTRY in partnership with Account Me IN

I understand that by signing this release of information form, I am authorizing the disclosure of my pictures, videos, and data as described above. I acknowledge that this authorization is voluntary and can be revoked at any time by providing written notice to the recipient.
Signature*

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Date*

MonthDayYear
Date
LEVELED UP REENTRY COMPLAINT AND GRIEVANCE PROCEDURES
A. Your Right to Make a Complaint

You have the right to make a complaint if you believe that you have been treated unfairly by Leveled Up REENTRY. A complaint cannot be processed as both a program complaint and as a discrimination complaint.

B. Grounds for a Program Complaint

1. If you have a complaint about the services you are receiving or have received through Leveled Up REENTRY:

a) Talk to your navigator to see if your complaint can be resolved.

b) If the problem cannot be resolved to your satisfaction then you may submit a written complaint to the Leveled Up REENTRY.

2. If you have a complaint arising from actions taken by or on behalf of Leveled Up REENTRY staff or subcontractors you must submit a written complaint to the Leveled Up REENTRY within one year of occurrence at:
Complaintants will be advised, in writing, of the status of the complaint at each step of the process:
1. Written response will be issued to complainants within ten (10) working days of receipt of any written complaint or attempt to file a complaint.
2. If a complaint is filed and further action is required by the complainant, the complainant will be advised in writing of the actions to be taken, a specific and reasonable time frame for such actions, and that failure to take such action without good cause may be considered as intent to withdraw the complaint.
3. All resolutions, agreements, or actions affecting a change in the status of a complaint will be confirmed in writing.
Participant initial*

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Date*

MonthDayYear
Date
Leveled Up Re-Entry is committed to a policy of equal opportunity that fosters an environment free of barriers and discriminatory practices. Leveled Up Re-Entry follows the spirit and intent of federal, state, and local employment laws and the Board of Directors and Founders of Leveled Up Re-Entry will not discriminate against any participant in a manner that violates the law.
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