IVAN'S HOUSE OF HOPE, INC.
Participant Intake & Assessment Form(Serving Fulton County Residents Only)
Date of Intake:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. ELIGIBILITY & FULTON COUNTY RESIDENCY VERIFICATION
Are you a current resident of Fulton County?
Yes
No
Intended Fulton County Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Proof of Residency Provided:
Utility Bill
ID/License
Official Legal Letter
Other
2. GENERAL INFORMATION
Full Legal Name:
First Name
Last Name
Preferred Name / Alias:
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
SSN (Last 4):
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
3. LEGAL & INCARCERATION HISTORY
DOC / CDC / Inmate ID Number:
Most Recent Facility:
Date of Release:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Length of Sentence Served:
Current Supervision Status:
Parole
Probation
None
Other
PO / Supervisor Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
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Reporting Requirements / Restrictions:
4. IMMEDIATE NEEDS ASSESSMENT (Check all that apply)
Immediate Needs Assessment Options
Identification: Needs State ID, Driver's License, Social Security Card, or Birth Certificate.
Food / Clothing / Hygiene: Needs grocery assistance, hygiene products, professional clothes for interviews or casual clothes.
Transportation: Needs bus passes, train cards, or transit vouchers.
Healthcare: Needs immediate medical attention, prescriptions, or insurance enrollment.
Mental Health: Needs counseling, therapy access, or medication management.
Life Skill Groups: Needs cognitive-behavioral restructuring, financial literacy, workforce development, and family reintegration. These programs address self-defeating behaviors, build employability, and teach practical daily living skills to ensure a stable, crime-free transition back into society. (can provide a referral or join ours)
Miscellaneous Support: Needs voting rights restored, a required drug screening, or an alcohol/drug/mental health evaluation.
5. EDUCATION & EMPLOYMENT BACKGROUND
Highest Level of Education:
No GED/HS
GED
HS Diploma
College/Trade
Current Employment Status:
Unemployed
Part-Time
Full-Time
Skills / Trades / Certifications:
Employment Goals:
Are you interested in Job Placement Services or Vocational Training?
Yes
No
Are you interested in GED/HS Diploma Placement or Testing?
Yes
No
6. PHYSICAL & MENTAL HEALTH
Do you have any immediate medical conditions?
Yes
No
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If yes, please specify:
Are you currently taking any prescription medications?
Yes
No
If yes, list medications:
Do you have active healthcare insurance?
Yes
No
Medicaid/Medicare
Are you interested in a referral for medical or dental care for the uninsured/low income?
Yes
No
7. ACKNOWLEDGEMENT, DISCLOSURE & SIGNATURE
Residency Confirmation:
By signing below, I certify that I am a resident of Fulton County and that all information provided on this form is accurate to the best of my knowledge.
Information Reporting & Disclosure:
I understand and agree that information gathered during this intake process, as well as updates regarding my program participation, may be reported to the Court, my Probation Officer (if applicable), or other relevant legal authorities.
Release of Information (ROI):
I acknowledge that a separate, formal Release of Information (ROI) form will be required if detailed case coordination or external record-sharing becomes necessary to facilitate my reentry plan.
Participant Signature:
Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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