McLean County Reentry Council

McLean County Reentry Council - Intake

Client Intake Form
To best assist you in your transition back into the community, please fill out as much as you can, and as much as you feel comfortable doing.

If you are filling this out on behalf of someone else, please fill out your own contact information and then fill the rest of the information out for the incarcerated individual.
I am filling this out for:

MyselfSomeone else
I am filling this out for someone who is currently incarcerated:
Name of Incarcerated Individual
- Full Name*
  
  First NameLast Name
- Preferred Name (if different from above):
- Phone Number*
  Format: (000) 000-0000.
- Preferred method of communication
  
  Voice calls to prison/jail that I am currently incarcerated inVoice call to cell phoneText message to cell phoneEmailPlease contact my trusted contact as it is difficult for me to communicate promptly (please fill in the trusted contact information below)Social Media (please Social media netwrok and name/link to profile below)
- E-mail
  example@example.com
- Social Media (please provide SM network and link to profile):
- I am currently incarcerated in (please tell us the name of the jail/prison):
  Name, phone number, email
- When is your anticipated release date?
  
  MonthDayYear
  Date
- I am currently receiving help during my incarceration for the following:
  
  Medical condition (high blood pressure, high cholesterol, heart condition, etc.)Mental health condition (generalized depression, anxiety, anger, etc.)Major mental health conditions (BIPOLAR, Schizophrenia, Borderline personality disorder, dissociative disorders, etc.)Getting my GEDPursuing education other than GED
- Do you have a place to go when you get out of jail/prison?*
  
  YesNot officially, but I am working through some good options.Not at this time, I could use some guidance.
- If "not officially", please let us know what options you are looking into so we can help:
- If you responded yes, or not officially, please let us know where you will be or hope to be going after you leave incarceration:
  
  Pre-incarceration ResidenceFamily or Friends HomeA Felon Friendly Homeless ShelterHalfway HouseMedical FacilityOther
- Will this be a permanent or temporary solution?
  
  PermanentTemporaryNot sure yet
- Planned address for reentry:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- What resources would you like assistance with (check all that apply):
  
  Getting documents (please choose specific documents below)Recovery (AA/NA, Celebrate Recovery, Winner’s Circle, outpatient treatment)Physical/Mental Health (please select specific needs below)Food/personal needs (list of pantries)Transportation (bus passes, help with accessing public transportation)Housing (shelters, private landlords, utility payments)InsuranceEducation (GED classes, college/trades)Employment (temp agencies, trades, list of employers that will work with those formerly incarcerated)Legal Assistance (expunging/sealing records, disability, select specific below)Religious or places of worshipOther
- Which documents do you need help obtaining (skip if not pertinent):
  
  Drivers license or state IDBirth certificateSocial Security CardOther
- Which "other" documents do you need help obtaining?
- Physical/Mental Health: What type of assistance do you need with physical/mental health (skip of not pertinent)?
  
  Finding a primary care doctorFinding an dentistFinding a mental health care providerFinding a specialistScheduling appointmentsFinding a pharmacy to refill prescriptionsFinding a recovery programGetting insuranceOther
- What "other" physical/mental health issue do you need help with?
- What type of legal assistance do you need (skip of not pertinent)?
  
  Expunging/sealing recordsDisabilityOrder of ProtectionOther
- What "other" legal assistance do you need help with?
- Current age:
- Birth Year:
- Which race/ethnicity do you identify with?
  
  White/CaucasianBlack/African AmericanHispanicAsianNative American or Alaska NativeMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderMultiracial or Two or More RacesPrefer not to answerOther
- Which gender do you identify with:
  
  FemaleMaleTrans Female (or transitioning)Tans Male (or transitioning)Prefer not to answer
- What have we missed? Or what was helpful? Please let us know below.
- How did you hear about us?
- Would you like to receive our newsletter or emails about upcoming events, rallies, or proposed legislation?
- Should be Empty:

McLean County Reentry Council - Intake