Correctional Facility Intake Checklist Form
Use this form to record intake details, housing needs, safety concerns, and property notes for a new correctional facility admission or transfer.
Intake Identification
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
*
Please Select
Male
Female
Non-binary
Prefer to self-describe
Prefer not to say
Booking/Intake Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Facility Status and Housing Needs
Admission Reason / Status
*
New Admission
Transfer
Return from Court
Return from Medical
Other
Custody Classification / Security Level
*
Please Select
Minimum
Medium
Maximum
Administrative Segregation
Protective Custody
Other
Housing Preference / Assignment Need
Please Select
General Population
Medical Housing
Mental Health Housing
Protective Housing
Temporary Holding
Other
Immediate Separation or Protective Housing Concern
*
No
Yes
Health, Safety, and Property Intake
Urgent medical or mental health concern at intake?
*
No
Yes
If yes, briefly describe the concern
Known allergies or special care notes
Property received at intake
Special intake notes for staff
Submit Intake Checklist
Should be Empty: