Reentry Program Intake Form
Share your details and referral information so Career Focus Employment Network can contact you within 2 business days.
Referral or Self-Application
Who is completing this form?
*
I am applying for myself
I am a case manager, probation/parole officer, or reentry partner referring someone
Referrer full name
Referrer organization/agency
Referrer phone
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer email
example@example.com
Participant Contact Information
Participant full name
*
First Name
Middle Name
Last Name
Participant phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant email
example@example.com
Best way to contact
*
Phone call
Text message
Email
Best time to reach
*
Morning
Afternoon
Evening
Residence and Release Status
County of Residence
*
Please Select
Hillsborough
Pasco
Hernando
Pinellas
Citrus
Other
Release Status
Not yet released
Employment, Support Needs, and Readiness
Current probation or parole status
*
Yes
No
Prefer not to say
Current employment status
*
Yes, full-time
Yes, part-time
No
What kind of help are you looking for?
*
Finding a job
Resume and interview help
Record expungement or sealing assistance
Job training or certifications
Support after getting hired
Not sure yet
Type of work interested in
Benefits, Transportation, Identification, and Additional Notes
Do you receive SSDI or SSI benefits?
*
Yes
No
Not sure
Do you have reliable transportation?
*
Yes
No
Sometimes
Do you have a valid ID or driver's license?
*
Yes
No
In progress
Anything else you'd like to share
Submit – We'll Be in Touch
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