Reentry Support Intake
You’re in the right place—please complete this intake form so we can better connect you with support. Everything you share is kept confidential and used only to guide resources.
A welcoming place that helps returning citizens land on their feet—through job training, mentorship, record relief, partner referrals, and basic needs support
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Let’s Get to know each other
Your Full Legal Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Best Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
Your Reentry Path
Current Supervision Type
*
Parole
Probation
None
Other
Parole or Probation Officer Name
When were you released?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you part of STAR Court?
Yes
No
Not Sure
Your Document Checklist
Which of these documents do you currently have?
State ID
Birth Certificate
Social Security Card
Medicaid Card
Health Insurance Card
Driver’s License
Other
Are you tapped in?
Do you currently have a smartphone?
Yes
No
Do you currently have a laptop or tablet?
Laptop
Tablet
Both
No
Do you currently have Wi-Fi access?
Yes
No
Sometimes
How would you describe your digital skills?
Beginner (1)
1
2
3
4
Advanced (5)
5
1 is Beginner (1), 5 is Advanced (5)
What’s your main technology goal?
What you need right now
Which of these immediate needs are true for you?
*
Housing
Food
Transportation
Clothing
Healthcare
Mental Health Services
Substance Use Support
Child Care
Employment
Education
Legal Assistance
ID/Document Help
Other
Looking Ahead
What career path interests you most right now?
What improvement can be made in your next 30 days?
Submit Intake Form
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