One Stop Shop Intake Application
Please fill out the following application. Once you have completed the application, we will be in contact with you within 72 hours.
Name
*
First Name
Middle Name
Last Name
Are you homeless?
*
Yes
No
Back
Next
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Gender
*
Please Select
Male
Female
Transgender
Non-Binary
Other
Age:
*
What are your pronouns?
*
Please Select
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Back
Next
Race
*
American Indian
Asian
Black
White
Latino
Middle Eastern
Other
Citizenship
*
Please Select
US Citizen
Other
Birth Country
*
Primary Language
*
Please Select
English
Spanish
Other
Highest Level of Education Completed
*
Please Select
Elementary
Middle/Jr. High
High School
GED
Trade School
2 Year Community College/Associates
4 Year/Bachelors
Masters
JD/MD/PHD
Marital Status
*
Please Select
Married
Domestic Partnership
Single/Never Married
Separated
Divorced
Widowed
Current Employment
*
Please Select
Working Full-Time
Working Part-Time
Self-Employed
Seasonal Worker
Looking for Work
Not Looking for Work
Primary Transportation
*
Please Select
Own Vehicle
Bus/Public Transportation
Uber/Lyft/Taxi
Family/Friends
Level of Income
*
Please Select
$0 - $15,000
$15,000 - $25,000
$25,000 - $35,000
$35,000+
Back
Next
Current Barriers
*
Lack of Career Information
Lack of Education
Low Motivation
Disability
Criminal Record
Health Challenges
Low Job Skills
Lack of Access to Job Training
Homelessness
Language Barrier
Access to Internet
*
Phone
iPad/Tablet
Home Computer
Work
Library
Reentry Status
*
Please Select
Served Full Sentence (Maxed Out)
Served Partial Sentence
Under Supervision (Probation or Parole)
Back
Next
Personal Documentation
*
Texas ID/US Government ID
Birth Certificate
Social Security Card
None of the above
What support services are you most in need of?
*
Housing
Employment
State Issue ID
Other
How long has it been since you were incarcerated?
*
Please Select
0-2 yrs
3-5 yrs
6-10 yrs
Over 10 yrs
How many times have you been incarcerated?
*
Please Select
1
2
3
4
5
More than 5
Back
Next
Do you have a community support system?
*
Yes
No
Do you have an active case with Child Protective Services (CPS)?
*
Yes
No
Have you ever had a plan for your reentry?
*
Yes
No
Would you be willing to share the nature of your conviction? (Optional)
Submit
Should be Empty: