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  • ANCHORPATH LIVING – REENTRY INTAKE & TRANSITION APPLICATION

  • Guiding You Home with Stability and Care
  • Providing structure, stability, and second chances through independent living.

  • FOR OFFICE USE ONLY

  • Intake Date:
     - -

  • GENERAL INFORMATION

  • Date of Interview:*
     - -
  • Format: (000) 000-0000.
  • Date of Birth:*
     - -
  • Government ID Verified:*
  • Marital Status:*
  • Veteran Status*

  • EMPLOYMENT & INCOME

  • Employment Status:
  • Employment Status:*
  • Interested in Job Training or Continuing Education*

  • MEDICAL & BEHAVIORAL HEALTH

  • History of Substance Use Treatment*

  • LEGAL & HOUSING HISTORY

  • On Probation or Parole*
  • Paying Restitution/Fines/Court Fees*

  • REENTRY & TRANSITION PLANNING

  • Level of Independence Upon Release*

  • RISK & BEHAVIOR INDICATORS

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  • History of Violence or Infractions While Incarcerated*
  • History of Substance Relapse or Non-Compliance*
  • Relapse Prevention Plan in Place*

  • SUPPORT NETWORK & ACCOUNTABILITY

  • Connected to Programs (NC Works, Project Reentry, etc.)*
  • Allow APL to Coordinate with Case Manager*

  • SUPPORT NEEDS & GOALS

  • LIFESTYLE & HABITS

  • Smoke/Vape*
  • Consume Alcohol*
  • Drug Use Past 12 Months*

  • PERSONAL HISTORY & STABILITY

  • Experienced Homelessness*
  • Lived in Shared Housing Before*

  • SERVICE PREFERENCES

  • Open to Weekly Case Management Check-Ins*
  • Open to Workshops/Classes*

  • EMERGENCY PLANNING

  • Advance Care Plan / Healthcare POA*
  • DOCUMENTATION CHECKLIST

  • STAFF USE ONLY – REENTRY READINESS ASSESSMENT

  • Participant Demonstrates Independent Living Readiness
  • Understands Program Structure and Rules

  • SIGNATURES

  • Participant Acknowledgment
    I understand that AnchorPath Living is a structured independent-living program, not a
    halfway house or treatment facility, and that continued participation depends on
    compliance with all program rules and guidelines.
  • Date:*
     - -
  • Date:
     - -
  • Confidentiality Notice: All information provided in this application will remain confidential and is used solely for determining eligibility, placement, and support within AnchorPath Living's housing program. Information will not be shared with outside parties without written consent, except as required by law or supervision conditions.
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  • AnchorPath Living, LLC | info@anchorpathliving.com | 336-608-9612 | www.anchorpathliving.com
    Page 1 of 7 – AnchorPath Living Reentry Intake & Transition Application

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