Intake Form for Re-Entry Housing

The Cynoya - Intake Complete Form - Re-Entry Housing

Please fill out this form completely for placement of client
Staff / Sponsor Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
- Inmate's Legal Name (as listed with DPSCS / BOP):*
  
  First NameLast Name
- Preferred/Nick Name
- Gender*
  
  FemaleMaleOther
- Date of Birth*
  
  MonthDayYear
  Date
- Last 4 SSN
- Phone Number
  Please enter a valid phone number.
- SID Number (if applicable)
- Emergency Contact Name*
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.
- Relationship?
- Secondary Emergency Contact Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.
- Relationship?*
- Preferred Housing Location*
  
  Baltimore CityBaltimore CountyWashington, DCOther
- Room Type Request*
  
  Shared Room ($750)Private Room ($950 - $1100)
- Move-in Date Requested
  
  MonthDayYear
  Date
- Inmate / DOC / BOP Number:*
- Facility Name*
- Housing Unit / Cell Block / Tier (if applicable)*
- Cell Number (if known):
- Custody Type:*
- Projected Release Date:*
  
  MonthDayYear
  Date
- Release Type:*
- Parole or Supervision Officer (if already assigned):
  
  First NameLast Name
- Parole Office/Agency
- Parole or Supervision Officer Phone Number
  Please enter a valid phone number.
- Assigned Case Mgr. / Counselor (if known):
  
  First NameLast Name
- Assigned Case Mgr. Phone Number
  Please enter a valid phone number.
- Assigned Case Mgr. Email
  example@example.com
- Sources of Income (check all that apply)*
  
  SSISSDIRetirement (Pension)VA BenefitsEmploymentOther
- Monthly Income Amount*
- Currently Employed?
  
  NoYes
- If Yes, Currently Employer Name?
- Employer Contact Info
- Do you have a payee or case manager for your benefits?
  
  NoYes
- If Yes, name & contact number?
- Amount of caseworker benefits?
- Do you receive any food assistance?
  
  SNAPOther
- If Other, what is the food assistance type and amount?
- Medical Conditionals (check all that apply)
  
  HypertensionAsthmaVision ImpairmentDiabetesChronic PainHearing ImpairmentHeart DiseaseMobility LimitationsOther
- If Other, please specify
- Mental Conditionals (check all that apply)
  
  DepressionPTSDDrug Abuse HistoryAnxietySchizophreniaBipolar DisorderNone ReportedOther
- If Other, please specify
- Are you currently using any illegal substances?*
  
  YesNo
- Are you willing to follow a drug‑free policy on the property?*
  
  YesNo
- List of Current Medications (if any)
- Do you need assistance managing medications?*
  
  NoYes
- TB Screening (Required)
  
  A tuberculosis (TB) screening is required to help protect the health and safety of all residents and staff living in a shared housing environment. Requiring a TB screening is a standard public health practice in congregate and transitional living settings and demonstrates a commitment to maintaining a safe, healthy living space for everyone in the home.
- Have you had a TB test within the last 12 months?*
  
  NoYes
- If no, are you willing to complete a TB test?
  
  YesNo
- I understand that my health history plays a vital role in identifying eligibility in this program. I certify that the information on this Health Screening is accurate to the best of my knowledge. I also understand that If any of this information has been falsely stated, it is grounds for immediate termination from the program.
- Do you need assistance from parole officer/case manager in obtaining any missing documents?
  
  NoYes
- Mental Conditionals (check all that apply)
  
  State IDDriver’s LicenseSocial Security CardBirth CertificateMedicaid/Medicare CardVA CardBank card / prepaid cardDOC re-entry paperworkRe-entry plan from case managerProof of income letterOther
- If Other, please specify
- The Cynoya provides housing only. We do not offer or provide medical services, nursing care, personal assistance, supervision, therapy, case management, transportation, medication management, or support services of any kind.
- Trade Schools or Certifications You’re Interested In?
  
  Barber CollegeBartending SchoolCDL / Trucking SchoolHVACElectricianConstruction / CarpentryPlumbingWeldingCulinary / Food HandlerSecurity Guard LicenseMedical Tech / Surgical TechEntrepreneurship trainingOther
- Do you currently have any of the following Trade skills?
  
  HVACElectricianConstruction / CarpentryPlumbingWelding
- Do you currently have any of the following IT skills?
  
  AICodingGamingCybersecurity
- Do you need interview clothing?
  
  NoYes
- Please check any areas you need help with:
  
  Anger managementLife skills classesConflict resolutionFinancial literacyBudgetingCredit repairSubstance abuse support (AA/NA/SMART Recovery)Mental health counselingLegal document supportFamily reunificationTechnology skills (email, phone, internet)
- I understand that participation in the program may require a background check for the safety of all residents.
  
  I consent to a criminal background check.I have provided accurate information regarding any prior convictions.
- Copy of Identification Front
  
  Cancelof
- Copy of Identification Back
  
  Cancelof
- I acknowledge that The Cynoya Independent Living Housing offers shared housing with established house rules, expectations, and program guidelines designed to ensure a safe, respectful, and clean living environment for all residents. I agree to comply with all rules and to complete the intake process truthfully and in good faith.
- Signature
Should be Empty:

The Cynoya - Intake Complete Form - Re-Entry Housing