Spiritual Support Intake Form
This form is for Lake County Jail staff to request a spiritual support visit for an incarcerated relative. The information provided will help us coordinate the visit and offer the right support. Please answer each section as completely as possible. Our team will review and follow up to confirm. Thank you for partnering with us to make spiritual and cultural care available.
Name of Staff Submitting Request
*
First Name
Last Name
Email
example@example.com
Title/Position
*
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Spiritual Support Intake Form
Section 1. Incarcerated Individual Information
Name of Relative
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Non-binary
Other
Tribal Affiliation
*
Big Valley Band of Pomo Indians
Elem Indan Colony
Habematolel Pomo of Upper Lake
Koi Nation
Middletown Rancheria of Pomo Indians
Robinson Rancheria of Pomo Indians
Scotts Valley Band of Pomo Indians
Unknown
Other Tribe (please list)
Inmate/CDC Number
Housing Unit
*
Sentence Length (If known)
Release Date (If known)
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Spiritual Support Intake Form
Section 2. Request for Spiritual Advisor Support
Type of Support Requested (check all that apply)
*
Spiritual conversation, emotional processing
Ceremonial support (prayer, songs, cultural practices)
Grief or Loss
Support with reentry planning (spiritual/cultural)
Substance use support (Red Road)
Cultural Group
Other
Please describe why you are requesting spiritual support from KNWI
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Spiritual Support Intake Form
Section 3. Appointment Scheduling
Male Provider: Kyle Bill
Male Appointment
*
Female Provider: Rose Steele
Female Appointment
Submit
Should be Empty: