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Interested Candidate Form
Personal Information
Full Name
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DOB
*
Phone Number #
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Current Projected Release Date
*
Gender
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Male
Female
Emergency Contact Name
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Emr. Contact Phone #
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DOC #
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email
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Questions
What is your current level of education?
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High School Diploma
Some College
AA/BA/MA
GED
Other
Do you have children/dependents? Please list the number of dependents or any additional information.
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Will you transition to Community Corrections?
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Yes
No
Not Sure
Do you need housing assistance?
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Yes
No
Not Sure
Is there a location or environment that is not safe for you to be in?
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Yes
No
Not Sure
If you are in recovery, please select which stage of change?
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Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Are you seeking family programming?
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Yes
No
Possibly
Do you have a vehicle/transportation?
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Yes
No
Possibly
Will you release on psychotropic medication?
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Yes
No
Possibly
Will you need wheelchair accommodations or need support with mobility?
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Yes
No
Not Sure
Are you currently pregnant?
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Yes
No
Not Sure
Are you interested in MAT services?
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Yes
No
Not Sure
If you are currently on medication, will you release with bridge medication?
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Yes
No
Not Sure
Are you seeking additional Peer Support services?
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Yes
No
Not Sure
Are you seeking employment?
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Yes
No
Not Sure
Have you ever worked with an advocate?
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Yes
No
Not Sure
Do you require medical accommodation?
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Yes
No
Not Sure
Are you fluent in English?
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Yes
No
Are you seeking 12-step programming?
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Yes
No
Not Sure
Do you have personal limitation that we should be aware of? Please explain.
*
What vocational/job skills are you seeking? Please explain.
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What does “success” look like to you? Please explain.
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Do you have mandatory reporting requirements? Please explain.
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What hobbies do you have or would you like to know more about? Please explain.
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On a scale of 1-10 with 1 being “not at all” and 10 being “extremely”, how much stress/worry do you have about coming home? Please explain.
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Do you have religious or culture preference? Please explain.
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Please list 3 areas of hobbies/activities that are of interest to you. Please explain.
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Please list 2 long term and 2 short term goals and barriers upon re-entry which may need to be addressed to achieve these goals. Please explain.
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Please explain any additional information about yourself or important details specific to your release and re-entry.
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