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Resources Reentry Re-entry Intake Form

Re-entry Intake Form

Full Name
First NameLast Name
E-mail

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
Area CodePhone Number
Birth Date
MonthDayYear
Gender
Current Age
Ethnicity
African-AmericanHispanicWhiteOther
Religion
JewishChristianMuslimBen NoachUnaffiliatedOther
Emergency Contact: Name
Emergency Contact: Number
Emergency Contact: Relationship
B. Family Information
The Hinda Institute has my permission to contact any of my extended family for additional information or to assess their need for services.
Sign your name to agree
Today's date
MonthDayYear
Are you in contact with any of your family or friends?
YesNo
Father's Name
First NameLast Name
Father's Phone Number
Area CodePhone Number

Father's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Name
First NameLast Name
Mother's Phone Number
Area CodePhone Number

Mother's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Spouse Name
First NameLast Name
Spouse Phone Number
Area CodePhone Number

Spouse Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Child 1 Name
First NameLast Name
Child 1 Phone Number
Area CodePhone Number

Child 1 Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Child 1 age
Child 2 Full Name
First NameLast Name
Child 2 Phone Number
Area CodePhone Number

Child 2 Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Child 2 Number
Friend Full Name
First NameLast Name
Friend Phone Number
Area CodePhone Number

Friend Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

C. Information to determine your reentry needs and services
Reason for incarceration (check as many as apply)
Addiction relatedMental Health relatedWhite collar crimeRobberyCon/FraudSex offenseDomestic abuseMurderViolent crime
Prison Sentence
less than 3 years3 to 5 years6 to 10 years11 to 15 yearsmore than 15 years
Date of release from prison
MonthDayYear
Date of parole, probation
MonthDayYear
Release from house arrest or halfway house
MonthDayYear
Will you be required to wear an ankle monitor or bracelet?
YesNo
Do you have any other restrictions, warrants or restraining orders placed against you?
YesNo
If yes, please specify
Have you had prior mental health hospitalizations?
YesNo
Do you see a mental health provider or social worker?
YesNo
Are you open to seeing one on release?
YesNo
Are you interested in speaking with a rabbi on release?
YesNo
Education
Elementary schoolHigh schoolVocational schoolCollege educationJewish education
Previous Occupation
Are you a veteran?
YesNo
D. Impact of services already provided in correctional institution
Did you receive training while in the correctional institute?
YesNo
If yes, specify all that apply
Jewish education or ethicsTechnical skillVocational trainingGEDSocial skillsOther
Specify who delivered the training
Hinda InstituteAlephCorrectional institute
How did this training help you? Explain
What other services did the Hinda Institute provide to you in the institution?
VisitationCounselingHolidaysAdvocacyLibrary
How did these services help you? Explain
E. Survey to determine future services
How can the Hinda Institute help you now?
EmploymentTrainingHousingFamily SupportSocial Events and HolidaysCounselingClothingFoodPhoneMedical InsuranceSocial Security Benefits
Any additional needs? Please specify
F. Can you volunteer?
How can you help?
Calling for fundraising campaignDonate or encourage friends to contribute through social mediaProvide a critical second chance by considering job opportunities for those who have recently reentered societyTutor or visit with a person in a correctional institution (volunteer training is provided)Delivering holiday packages within Chicago and suburbsHelp with Programming and eventsAssist with driving family members to prisons in IllinoisStart a pen pal relationship with someone who is incarcerated (communications go through the Hinda Institute and volunteers use pen names)Help with mailingsWeb design and blogsHelp prepare mitigation narratives - understanding and writing people's stories for critical hearings and submissions (certain criteria applies for potential volunteers)Editor for courses and articlesAssist with data entry, scanning document, addressing letters and other administrative tasks (certain criteria applies for potential volunteers)Help with writing and research assignments (certain criteria applies for potential volunteers)
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The Hinda Institute 9401 Margail Avenue Des Plaines, IL 60016
847-296-1770

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