Pathways to Freedom Inc. — Partner With Us Form
Please complete this service request form. The form mirrors the PDF sections and options as closely as possible. If you are requesting services for someone else, answer as accurately as you can.
Section 1: Your Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pronouns
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Text Message
Best Time to Contact
Morning
Afternoon
Evening
Anytime
Section 2: Who Are You Requesting Services For?
Who are you requesting services for?
*
Myself
My child/youth
My spouse/partner
A family member
A client I work with
A student
My organization/program
Someone currently incarcerated
Someone returning to the community
Other
Relationship to the person
Does this individual know this request is being submitted?
*
Yes
No
Not applicable
Section 4: Tell Us About Your Need
What type of support are you seeking?
*
Please briefly describe what is happening and what help is needed.
*
Primary goals for receiving services
How soon do you need services?
*
Immediately
Within 1–2 weeks
Within 30 days
Within 60–90 days
I am exploring options
Section 5: Reentry & Justice Involvement
Current or past justice-system involvement
Currently incarcerated
Recently released
On probation
On parole
Previously incarcerated
Juvenile justice involvement
Court involvement
No justice-system involvement
Prefer not to answer
Other
Support needed during reentry
Mental health support
Housing
Employment
Education
Transportation
Life skills
Family reunification
Community resources
Probation/parole support
Substance-use recovery resources
Other
Section 6: Mental Health & Wellness
Areas you would like support with
*
Stress
Anxiety
Depression
Trauma
Grief/loss
Anger management
Emotional regulation
Relationship/family concerns
Adjustment after incarceration
Identity/self-esteem
Life transitions
Coping skills
Other
Are you currently receiving mental health or behavioral health services?
*
Yes
No
Unsure
Prefer not to answer
If yes, would you like assistance coordinating with your existing supports?
Yes
No
Not applicable
Submit
Should be Empty: