Re*Membering Intake

Intake Date

MM

DD

YYYY

Name *

First Name

Last Name

DOB

MM

DD

YYYY

Race/Ethnicity

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latino or Spanish Origin

Enrolled Member?

Yes

No

U.S. Citizen?

Yes

No

Highest Education Level:

Grade/High School

H.S. Diploma

GED

GED in Prison

Some College

Associate's Degree

Trade Certification

Undergraduate Degree

Master's PhD, advanced degree

Military Service?

Yes

No

If yes, did you ever see combat?

Yes

No

Gender Identity

Female

Male

Transgender

Gender non-conforming

Something else

Prefer Not to Say

Sexual Orientation

Heterosexual (Straight)

Homosexual (Gay/Lesbian)

Bisexual

Something Else

Prefer Not to Say

Marital Status

Single

Married

Divorced

Separated

Widowed

Were you convicted under accomplice liability?

Yes

No

Possibly

I Don't Know

Incarcerated after probation revocation?

Yes

No

Date Entered CCCF:

MM

DD

YYYY

Expected Release Date:

MM

DD

YYYY

AIP

STTL

Good time/Earned time

Maximum

Type (Check all that apply)

Full-time work

Part-time work

Veterans benefits

TANF

SSI/SSDI

Child support

Food stamps

Tribe per capita

Current Debt

Child Support

Medical

Court Fines/Fees

Restitution

Student Loans

Other

At the time of the charged crime:

Homeless

Moved around a lot (please describe below)

Stable and long-term (please describe below)

As an adult, have you ever been homeless?

Yes

No

Release Plans

Unknown

Place I Own

Stay w/ Family or Friend

Residential Program

Transitional Housing

Other

Non-biological minor children cared for before CCCF

Yes

No

Current Spouse/Significant Relationship

Yes

No

History of being in DV relationship

Yes

No

DV relationship related to current convictions

Yes

No

Do you have an open DHS case?

Yes

No

If yes, do you have an attorney?

Yes

No

If no current DHS case, did you ever have a DHS case?

Yes

No

If you did have a DHS case, when did it close?

While Incarcerated

Before Incarceration

What was the outcome of the DHS case?

TPR

Guardianship

Child(ren) in care/custody of other parent

Child(ren) in care/custody of client

Other

Self-health rating when entered CCCF:

Poor

Fair

Good

Excellent

Self-health rating now

Poor

Fair

Good

Excellent

Mental Health (MH) diagnosis:

Yes

No

On Medication?

Yes

No

History of drug/alcohol abuse

Yes

No

If yes, drug of choice?

Alcohol

Prescription Drugs

Meth

Heroin

Cocaine

Marijuana

Other

Drug/alcohol abuse related to current conviction(s)?

Yes

No

Ever been in drug/alcohol treatment?

Yes

No

Quality of community support in release county:

Poor

Fair

Good

Excellent