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

Contact Information
Full Name*

First NameLast Name
Preferred Name (if different from above):
Phone Number*
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):

Current Situation
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