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Powerhouse Community Development Corporation
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Incarcerated and Detained Application
*
Indicates required field
Name
*
First
Last
Doc Number
*
Complete DOC Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number if available
*
Social Security Number
*
Date of Birth
*
Marital Status
*
Married
Single
Divorced
Widowed
Name of spouse or ex-spouse
*
First
Last
If married tell us a little about the situation:
*
Legal Status: What county are you supposed to parole to? (What county did you get convicted in, what county is your plan supposed to be in)
*
What was the conviction for?
*
Do you have any sexually related offense(s):
*
No
Yes
Do you have any violent offense(s):
*
No
Yes
Do you have any drug related charge(s):
*
No
Yes
Name of current institution Probation/Parole Officer or Case Worker if you know who it is:
*
Phone and Extension
*
Are there any circumstances regarding your Probation/Parole?
*
What is your expected release date? How certain is that?
*
How much time have you served this incarceration?
*
How much time total have you spent incarcerated in your life?
*
Past drug or alcohol use:
*
Have you ever been in a drug or alcohol treatment program? If yes how many?
*
What type of drugs have you dealt with?
*
Are you taking prescription medication? If yes why are you prescribed medication? (Explain purpose)
*
Name the medication(s) you take:
*
When was your last doctor's appointment for your medication(s)?
*
Have you ever been admitted to a mental facility or a mental treatment program? If yes where, how long and for what?
*
Spirituality: Do you see God as a part of your life? If yes explain.
*
Past work experience? Explain.
*
Relationships: Are you in a committed "romantic" relationship? If yes, how long, do you feel its a healthy relationship and why or why not?
*
How many kids do you have?
*
Do you have a relationship with your kid(s)?
*
Emergency Contact:
*
First
Last
Emergency Contact Relationship:
*
Emergency Contact Phone Number:
*
Why do you want to live at the Fresh Start House?
*
Do you feel you have a problem with decision making, alcohol or drugs? Explain.
*
List a few short term goals for your life (the next six months):
*
Please state any other information that you thinik might be helpful so that we can serve you better:
*
Submit
Home
About
From the Desk of the Executive Director
Affiliates and Partners
Blog
Programs
Parenting Programs
Food Programs
>
COVID-19 FOOD PROGRAM
Community Garden
GED Program
Summer Camp-Columbia
Summer Camp-Marshall
Recovery Support Services
>
Central Missouri Behavioral Health Network
Domestic Violence
Fresh Start Missouri Reentry Program
Youth Power
>
Healthy Choices
Youth Survey
Fatherhood
>
Fatherhood Program
Dad Goes to School Initiative
Connecting with Your Kids
First Offenders Program
Donations
News
Media
>
Christmas Character Costume/Holiday Face Mask Contest
Newsletters
Contact Us
DONATE
Resources
CoMoGives