"*" indicates required fields Step 1 of 7 14% Unique IDThis field is hidden when viewing the formDate of Submission MM slash DD slash YYYY Client0Aaron Nicholas BassettDAVID R FROHWERKWright Elijah MNashala RichmondDaniel BurtonDeondre Dewayne LangstonShaquielle O'Neal JenkinsTerrance AdamsStephanie Stephanie VictorRichard A. SackettPhilip Andrew JonesAndre BaconGregory Peet PrestonBrian J NordbyDejuan M JohnsonMaisha J RickmonJordan keeker jordan leeSamuel Leroy StahlAsia Imini MaloneAndy Gene KnoxShania Crystal BarnettTanna M ClarkCourtney Danielle SmithLillie Terriona HornerKenneth HuntLaymond L. RadfordBernadoni B. ChasrlierJarece ML JohnsonCarrie Ann BrashearsTeresa AlexanderJeffrey Ray WilliamsChristopher BrooksDavid Ovilson Torres RomeroBranden D. HarlessJonathan M. MaguireJeremy A. JustusVictor Keon ButlerBrian Andre EinesHarold P. StanfieldShennay L TurnerJesika DavisShirwanda BooneBryson Dominic ForteVicente GaytanDevon Mikal HillKenesha M MccollumThomas FoxAndrew C. 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CarrollRyan Scot NoeRoy CheathamDanny RoadsPatricia Marie BurnettWilliam R HaleKeshia HarrisJohn T. DixonMicha M McLaughlinTiffany N GoodallHubert DaShawn WilliamsMatthew E RunionLouis AndradeJamal Headen AzizLEE HARLEY DAVIDSON BATESDarrell L. HallMegan Elizabeth DavidsonJeremias WoodlandTyrone L ThomasAdrien Rice MCameron Z ColemanHolly Renee NethercuttAmanda M DurhamAntwaun Demon RichmondKandice Murphy-HicksKevaughn L EnglishDerek M. JacksonRamone Andre CorkAshleigh Nicole PrattKayila HughesBonnie Rene Bambi Lynn IrvinBrandon RomeroDawon A WadeDavion L. WrightTommie ThomasRichard E. WallaceKevin A EvansCurtis Donell WashingtonLanny J McintoshNathena Leann LynchShatasha N HendersonBryan Wayne TateJaylun J DearmanAdam Eric DunlapBrian YoungLaquan Higginsshaun edward mathenyJordan Patrick StackhouseDaniel R. DavisJonathan CassOtis Wayne BrownGregory SmithElvis G BrownAryhan Datez LewisBrianne Lashelle MotleyShannah Sue ForresterDaveyon L. 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Gibsoncaleb nathaniel crismanGregory Duncanterriyana anye scottMichelle GorbyAnthony Michael KingYour InformationName* First Middle Last Suffix* None Apply Jr Sr I II III IV Date of Birth* MM slash DD slash YYYY Age*Social Security NumberAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*AdamsAllenBartholomewBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushScottShelbySpencerSt. JosephStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitleyEmail Cell PhoneHome PhoneWork PhoneIncome Range* Under $10,000 $10,001 to $15,000 $15,001 to $20,000 $20,001 to $25,000 $25,001 to $30,000 $30,001 to $35,000 $35,001 to $40,000 $40,001 to $45,000 $45,001 to $50,000 $50,000 & up Gender* Female Transgender female Male Transgender male Non-binary Other Pronouns* She/Her/Hers He/Him/His They/Them/Theirs Race* African American/Black American Indian/Alaskan Native Asian Bi-racial Caucasian/White Hawaiian/Pacific Islander Multi-Racial Other Ethnicity* Hispanic Non-Hispanic Marital Status* Common Law Divorced Domestic Partnership Married, living separately Married, living together Separated Single (never married) Widowed Military Status* Active Duty Never Served Spouse of Active Duty Member Spouse of Veteran Veteran Primary Language* English Spanish Arabic Chinese Polish Other Emergency ContactName First Last Relationship* Spouse Son/daughter Parent Other relative Case worker Friend Other Phone* Supportive InformationPrimary Interest at Program Entry* Education/Training Digital Literacy/Computer Instruction Financial Education/Counseling Income Supports/Public Benefits Job Placement/Career Development Other Health Insurance Status* Insured through a government program No insurance at all Private insurance through a household member's employer Private insurance NOT through a household member's employer Highest Grade Completed* No High School Diploma GED/HSE High School Diploma Some College Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree Are you currently working?* Yes No Employment Status Part-time (less than 35 hours per week) Full-time (35 hours or more per week) Unemployed & seeking employment Not in the workforce (homemaker, retired, disabled) Other Is your current job also your longest job?* Yes No Was your previous job your longest job?* Yes No Vocational Training/Bridge Program History* No Vocational Training/Bridge Program History Some Vocational Training/Bridge Program(s) History Completed Vocational Training/Bridge Program(s) Are you in school or a training program?* Yes No Do you have a valid driver’s license?* Yes No Do you have a valid CDL driver’s license?* Yes No Do you have a valid chauffeur’s license?* Yes No In the past 12 months, number of full months worked*Please enter a number from 0 to 12.For the past 12 months, your earned income (after tax, this includes SS and disability):*For the past 12 months, your gross household income:*Do you receive SSI/SSDI?* Yes No Including yourself, how many people live in your household?*Please enter a number greater than or equal to 1. Do you have children ages 0 – 17?* Yes No How many children ages 0 – 17?*Please enter a number greater than or equal to 1.Child 1: Date of Birth* MM slash DD slash YYYY Child 2: Date of Birth* MM slash DD slash YYYY Child 3: Date of Birth* MM slash DD slash YYYY Child 4: Date of Birth* MM slash DD slash YYYY Child 5: Date of Birth* MM slash DD slash YYYY Child 6: Date of Birth* MM slash DD slash YYYY Child 7: Date of Birth* MM slash DD slash YYYY Child 8: Date of Birth* MM slash DD slash YYYY Child 9: Date of Birth* MM slash DD slash YYYY Do you have a relationship with your children?* Yes No Are you interested in improving or strengthening a relationship with your children?* Yes No Do you owe child support?* Yes No Do you currently pay child support?* Yes No Do you have a physical or mental disability?* Yes No Criminal Convictions* No Convictions Convicted of Felony/Felonies Convicted of Misdemeanor(s) only Don't know Select the level of your most recent felony conviction.* A B C D F 1 F 2 F 3 F 4 F 5 F 6 Are you on probation?* Yes No Are you on federal probation?* Yes No Are you on parole?* Yes No Are you on home detention?* Yes No Are you in a work release?* Yes No Officer or Case Manager Name First Last Officer or Case Manager Phone NumberDo you currently have charges pending?* Yes No In what county are your charges pending?* Boone Hamilton Hancock Hendricks Johnson Madison Marion Morgan Shelby Other When were you released from prison?* Never been to prison Currently incarcerated Less than 30 days 1 - 3 months 4 - 6 months 7 months - 1 year More than 1 - 3 years More than 3 - 5 years More than 5 - 10 years More than 10 years Which describes your current living situation?* House or apartment owned by you or a family member House or apartment rented by you or a family member – subsidized (Low income, Section 8 housing) Housing with work release, half-way house, recovery/sober living programs House or apartment rented by you or a family member – unsubsidized Household stays in a house or apartment for free Household is homeless (without a roof) or staying in a shelter What kind of assistance do you need?* Birth Certificate Employment Food or Clothing Housing Navigation Assistance State ID Transportation Free HIV Testing Substance Use Treatment/Support Financial Literacy/Budgeting Parenting Classes Mental Health Support/Treatment Educational Training Income Supports/Public Supports (SNAP, SSDI, etc) Peer Recovery Coaching MRT (Moral Reconation Therapy) Other What other assistance do you need?Do you need assistance with substance use?* Yes No Are you pre-release?* Yes No Are you currently incarcerated?* Yes No (i.e. Marion County Jail, VOA, Duvall, Craine House etc.)What is your expected release date?* MM slash DD slash YYYY