REQUEST SERVICES - Pathways to Freedom Inc.
Pathways to Freedom Inc. Empowering pathways to a new beginning. Thank you for your interest in Pathways to Freedom Inc. This form helps us understand your needs and determine how we may best support you, your loved one, or your organization. Our services focus on mental health support, trauma-informed care, reentry, life skills, community reintegration, and organizational support. Please complete the form below. A member of our team will review your request and contact you regarding next steps.
Your Information
Full Legal 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
Who Are You Requesting Services For?
Who are you requesting services for?
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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 you are submitting this request?
Yes
No
Not applicable
Tell Us About Your Need
What type of support are you currently seeking?
*
Briefly describe what is happening and what help is needed
*
What are your primary goals for receiving services?
How soon do you need services?
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Immediately
Within 1–2 weeks
Within 30 days
Within 60–90 days
I am exploring options
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 the reentry process
*
Mental health support
Housing
Employment
Education
Transportation
Life skills
Family reunification
Community resources
Probation/parole support
Substance-use recovery resources
Other
Mental Health & Wellness
What support areas are you seeking help 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
Would you like assistance coordinating with your existing supports?
Yes
No
Not applicable
Organization / Program Requests
Are you completing this form on behalf of an organization, program, or school?
*
Yes
No
Organization / Program / School Name
Describe the organizational support being sought
*
SUBMIT REQUEST FOR SERVICES
Should be Empty: