LOVE BEYOND WALLS - Participant Intake Form
Welcome to Love Beyond Walls. Thank you for taking the next step toward support. This intake form helps us learn more about you, your relationship or family circumstances, and the areas where you would like support. Please answer only the questions you feel comfortable answering. Information provided will be handled respectfully and used to help determine appropriate program support and next steps.
Participant 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
Text
Email
Best Time to Contact You
Morning
Afternoon
Evening
No preference
Your Connection to Incarceration
Which best describes your situation?
*
My spouse/partner is currently incarcerated
I am currently incarcerated
My spouse/partner is preparing for release
I am a returning citizen
I am a family member of someone who is incarcerated
I am preparing for reunification with my loved one
Other
How long has your loved one been incarcerated?
How would you describe your current relationship with your loved one?
*
Please Select
Married
Dating/Partnered
Engaged
Separated
Co-parenting
Family relationship
Other
What Brings You to Love Beyond Walls?
What are you hoping to receive from this program?
*
Emotional support
Relationship support
Couples support
Communication support
Conflict-resolution support
Reentry/reunification preparation
Family support
Support with loneliness or isolation
Support with maintaining connection
Support with rebuilding trust
Educational resources
Support group/community
Other
Please describe what is currently bringing you to Love Beyond Walls
Relationship & Communication
What areas of your relationship would you like to strengthen?
*
Communication
Trust
Emotional connection
Intimacy
Conflict resolution
Boundaries
Parenting/co-parenting
Financial communication
Rebuilding the relationship
Preparing for reunification
Other
How would you describe communication between you and your loved one?
*
Very strong
Good
Somewhat difficult
Very difficult
We currently have little/no communication
What is one change you would most like to see in your relationship?
Emotional Wellness
How have you been coping with the challenges associated with incarceration or separation?
*
Which areas have been difficult for you recently?
*
Stress
Loneliness
Anxiety/worry
Sadness
Anger/frustration
Relationship conflict
Family conflict
Parenting challenges
Financial stress
Social isolation
Uncertainty about the future
Other
What has helped you cope in the past?
Reentry & Reunification
Is your loved one expected to return home or transition back into the community?
*
Yes
No
Unsure
Not applicable
If known, anticipated release date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What concerns do you have about reunification or reentry?
Adjusting to living together again
Communication
Trust
Parenting
Intimacy
Household responsibilities
Employment/financial concerns
Family expectations
Setting boundaries
Emotional adjustment
Other
What would help you feel more prepared for reunification?
Submit
Should be Empty: