The Landing – Men’s Reentry Program Application

The Landing – Men’s Reentry Program Application

Complete this application for reentry services after incarceration, including your facility, release, supervision, and recovery details.
Who is completing this application?
Who is completing this application?

Other
Your name

First NameLast Name
Your agency/organization
Your phone
Please enter a valid phone number.Format: (000) 000-0000.
Your email
example@example.com
Applicant Information
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 of Social Security Number
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Last Address Before Incarceration

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Incarceration & Release
Current facility name
Facility type
County/State of facility
Inmate or DOC number
Expected release date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is release contingent on an approved home plan or address?
Institutional or reentry caseworker name

First NameMiddle NameLast Name
Caseworker phone
Please enter a valid phone number.Format: (000) 000-0000.
Caseworker email
example@example.com
Release conditions the program should know about
Is transportation from the facility needed on the release date?
Supervision
Will the applicant be on supervision after release?
Supervising officer first name
Supervising officer last name
County or office
Supervising officer phone
Please enter a valid phone number.Format: (000) 000-0000.
Supervising officer email
example@example.com
Are there any current pending charges or detainers?
Please explain the pending charges or detainers
Treatment & Recovery
Did you participate in treatment or recovery programming while incarcerated?
If yes, please describe the program(s) and any services received
Are you currently on medication-assisted treatment (MAT)?
MAT provider name
Which recovery program do you attend or plan to attend?

Other
Sobriety date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact
First name
Last name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
ID, Benefits & Employment
Which documents do you currently have?
Do you currently have health insurance or Medical Assistance?
Work history
Job skills, trades, or certifications
Highest level of education completed
Do you have children?
Marital status
Have you ever served in the military?
Referral & Payment
Who referred you?
Will you need a payment plan for the intake fee, deposit, or rent?
Desired move-in date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Agreement
I certify that the information in this application is true and complete to the best of my knowledge.
Full name

First NameMiddle NameLast Name
Signature
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

The Landing – Men’s Reentry Program Application

Who is completing this application?

Applicant Information

Incarceration & Release

Supervision

Treatment & Recovery

Emergency Contact

ID, Benefits & Employment

Referral & Payment

Agreement