Fresh Start Questionnaire

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): *

Do you have any violent offense(s): *

Do you have any drug related charge(s): *

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

Fresh Start Questionnaire

​Incarcerated and Detained Application

Incarcerated and Detained Application