PROGRAMS & INITIATIVES INTEREST FORM
Help us identify the Pathways to Freedom Inc. program or initiative that best fits your needs. Complete this form to share your interests and how we may support you.
Section 1: About You
Full Name
*
First Name
Last Name
Preferred Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Phone
Email
Text Message
Are you completing this form for
*
Myself
My child
My spouse/partner
A family member
A client
My organization
A student
Someone currently incarcerated
Someone returning to the community
Other
Section 2: Which Program Are You Interested In?
Please select the program or initiative you are interested in
*
Reentry Wellness Model
Behavioral Health Support
Fathers Behind Bars
Behind the Inc & Mic
Consulting & Training
Multiple Programs
I'm not sure (I would like help identifying the appropriate program)
Section 3: Your Current Situation
Which best describes your current situation?
Currently incarcerated
Recently released from incarceration
Preparing for release
On probation
On parole
Previously incarcerated
Justice-involved family member
Supporting someone who is incarcerated
Supporting someone returning to the community
Community member
Organization/service provider
Other
What are the primary challenges or needs you are currently experiencing?
Mental health/wellness
Trauma
Family relationships
Reunification with children
Parenting
Employment
Housing
Education
Life skills
Emotional regulation
Substance-use recovery
Community reintegration
Identity/self-esteem
Communication
Creative expression
Mentorship
Other
Section 4: Your Goals
What would you like to accomplish through participation in a Pathways to Freedom program?
*
What are your most important goals right now?
Improve emotional wellness
Strengthen family relationships
Reconnect with my children
Prepare for release
Successfully transition back into the community
Develop life skills
Improve decision-making
Develop coping skills
Find employment
Connect with community resources
Share my story
Develop creative skills
Build leadership skills
Develop a support network
Other
FATHERS BEHIND BARS
Complete this section if you selected Fathers Behind Bars.
Are you a father who is currently incarcerated or previously incarcerated?
*
Yes
No
Completing this form on behalf of a father
How many children are involved?
*
1
2
3
4+
What would you most like support with?
Rebuilding my relationship with my child/children
Communication with my child/children
Parenting while incarcerated
Preparing for reunification
Parenting after release
Emotional support
Understanding my child's needs
Developing a healthy co-parenting relationship
Other
Tell us about your family goals:
BEHIND THE INC & MIC
Complete this section if you selected Behind the Inc & Mic.
What type of creative expression interests you?
Writing
Poetry
Spoken Word
Podcasting
Storytelling
Interviews
Music
Video/Media
Publishing
Other
What would you like to share or create?
What do you hope your story or creative work will accomplish?
Inspire others
Educate others
Encourage positive change
Process my experiences
Advocate for reform
Build confidence
Develop creative skills
Create something for my children/family
Explore publishing/media opportunities
Other
REENTRY WELLNESS
Complete this section if you selected the Reentry Wellness Model.
Where are you in your reentry journey?
*
Preparing for release
Released within the last 30 days
Released within the last 6 months
Released within the last year
More than one year post-release
Supporting someone through reentry
What areas would you like support with?
Mental health
Emotional regulation
Coping skills
Life skills
Employment
Housing
Transportation
Education
Family reunification
Community resources
Peer mentorship
Goal setting
Other
BEHAVIORAL HEALTH SUPPORT
Complete this section if you selected Behavioral Health Support.
What type of support are you seeking?
Individual support
Group support
Mental health education
Trauma-informed support
Emotional wellness
Stress management
Coping skills
Anger/emotional regulation
Adjustment after incarceration
Family support
Other
Are you currently connected to a behavioral health provider?
*
Yes
No
Unsure
Prefer not to answer
ORGANIZATIONS & COMMUNITY PARTNERS
Complete this section if you are submitting this form on behalf of an organization.
Organization Name:
Your Position/Role:
What are you interested in?
Bringing a Pathways program to our organization
Referring individuals to a program
Co-developing a program
Hosting a program
Staff training
Community workshop
Program consultation
Program evaluation
Community partnership
Other
Tell us about your organization's needs:
AVAILABILITY
When would you prefer to participate?
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Flexible
Preferred format:
In person
Virtual
Hybrid
No preference
HOW DID YOU HEAR ABOUT US?
input43
Pathways to Freedom website
Google/Search Engine
Facebook
Instagram
TikTok
Community event
Referral
Friend/family member
School
Correctional facility
Community organization
Behavioral health provider
Other
ADDITIONAL INFORMATION
Is there anything else you would like us to know?
NEXT STEP
What would you like to happen after submitting this form?
Contact me about program eligibility
Schedule a consultation
Schedule an orientation
Receive more information
Discuss available programs
Submit My Interest
Should be Empty: