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Sheriff - Reentry Intake Form
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Intermediary Agency: Guilford County
Participant's Information
Enrollment Date
Date
form field Enrollment Date
must be in the format: MM/dd/yyyy
First Name
*
Middle Initial
Last Name
*
Suffix
Address
Gender
*
Value is not selected
-- Select one --
Male
Female
Transgender - Male to Female
Transgender - Female to Male
Date of Birth
Date
form field Date of Birth
must be in the format: MM/dd/yyyy
Email
*
Email
form field Email
is not in correct form
Main Phone
*
Phone
form field Main Phone
must be in the format: (000) 000-0000
Alternate Phone
Phone
form field Alternate Phone
must be in the format: (000) 000-0000
Marital Status
Value is not selected
-- Select one --
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Common Law
Race
Value is not selected
-- Select one --
African American
Asian
Bi-Racial
Latino
Caucasian
Multi-Racial
Native American
Hawaiian or Pacific Islander
Other
Ethnicity
Value is not selected
-- Select one --
Hispanic
Non-Hispanic
Highest Level of Education
Value is not selected
-- Select one --
Grade School
9th Grade
10th Grade
11th Grade
12th Grade
High School Diploma
High School Equivalency
Associate's Degree
Bachelor's Degree
Grad School
Preferred Communication Method
*
Value is not selected
-- Select one --
Phone
Email
Text Message
Other
Best time to be contacted
County ID#
(If previously incarcerated or supervised by the State of North Carolina)
OPUS ID#
Most Recently Released from
*
(Please check the appropriate box)
Value is not selected
-- Select one --
NC Prison
NC Probation/Parole
County Jail (NC)
Federal Facility
Another State
Referred from
Value is not selected
-- Select one --
NC DPS Prison
NC DPS Probation/Parole
County Jail (NC)
Another State
Community Agency
Self-Referral
Relative/Friend
Release Date
*
Date
form field Release Date
must be in the format: MM/dd/yyyy
Currently under NC Probation/Parole
Value is not selected
-- Select one --
Yes
No
Probation/Parole Officer Name
Probation/Parole Phone Number
Phone
form field Probation/Parole Phone Number
must be in the format: (000) 000-0000
Probation/Parole Email
Email
form field Probation/Parole Email
is not in correct form
End Date
Date
form field End Date
must be in the format: MM/dd/yyyy
Is the client a Registered Sex Offender?
*
Value is not selected
-- Select one --
Yes
No
NC County registered in
Value is not selected
-- Select one --
Alamance
Alexander
Alleghany
Anson
Ashe
Avery
Beaufort
Bertie
Bladen
Brunswick
Buncombe
Burke
Cabarrus
Caldwell
Camden
Carteret
Caswell
Catawba
Chatham
Cherokee
Chowan
Clay
Cleveland
Columbus
Craven
Cumberland
Currituck
Dare
Davidson
Davie
Duplin
Durham
Edgecombe
Forsyth
Franklin
Gaston
Gates
Graham
Granville
Greene
Guilford
Halifax
Harnett
Haywood
Henderson
Hertford
Hoke
Hyde
Iredell
Jackson
Johnston
Jones
Lee
Lenoir
Lincoln
Macon
Madison
Martin
McDowell
Mecklenburg
Mitchell
Montgomery
Moore
Nash
New Hanover
Northampton
Onslow
Orange
Pamlico
Pasquotank
Pender
Perquimans
Person
Pitt
Polk
Randolph
Richmond
Robeson
Rockingham
Rowan
Rutherford
Sampson
Scotland
Stanly
Stokes
Surry
Swain
Transylvania
Tyrrell
Union
Vance
Wake
Warren
Washington
Watauga
Wayne
Wilkes
Wilson
Yadkin
Yancey
Reentry Intake Needs
Please select services that you are in need of.
(Please select all that apply.)
Values are not selected
Housing Assistance
Food
Employment Assistance
Substance Abuse Treatment Services
Mental Health Treatment Services
Child Care
State ID Card/Driver's License
Clothing
Education/Vocational Training Services
Family Support Services
Other
Other
*
Email Address:
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