Texas Reentry Confidentiality Agreement

Texas ReEntry Services, Inc. Intake Sheet

Creating safer and stronger communities by providing ex-offenders opportunities and means to become productive, contributing members of society.

Revision C

CONFIDENTIALITY AGREEMENT

Client’s Name:    Date of Birth:

SS#:    Institutional #:    (TDCJ)

I, , authorize Texas ReEntry Services (TXRS) to release and receive any and all information regarding my participation in TXRS programs and services. This release covers all forms of information exchange whether verbal, written, or faxed. This release will expire one year from the date signed, unless rescinded through written notices from me delivered to Texas ReEntry Services.

In the event that I am referred by the criminal justice system, I understand that such information could effect my status with the criminal justice system and that this consent will remain until disposition of the legal action. Further, this information can be re-disclosed at a later date only to carry out the person’s official duties with regard to court action. I understand that TXRS has a legal obligation to divulge my address upon request from my parole officer or any member of the criminal justice system. Any re-release of information not pertaining to rehabilitation is not permitted.

Print Name:

Personal History

1. Name:    S.S. #:

2. Address:    Phone:

City:    State:    Zip:

3. Date of Birth:    Place of Birth:

4. E-mail address:

5. Gender: Male Female

6. Ethnic background:

White (Not Hispanic) American Indian Asian

African American (Not Hispanic) Hispanic Other

7. Do you possess a driver’s license? Yes No

Type:    State:    Number:

8. Do you use an alias? Yes No    If yes, please give A.K.A.:

9. Are you a naturalized citizen? Yes No

Date entered the U.S. (Month/Year):    Where Issued (City, State):

Certificate:    Date of final papers (Month/Day/Year):

10. Do you receive any of the following benefits? Check all that apply:

Social Security Check Government Assisted Housing TANF/AFDC

Veterans Check Medicare/Medicaid Food Stamps

SSI Disability Check Other

11. Emergency Contact Person:

Relationship:    Phone:

Address:    City:    State:    Zip:

Prison History

1. Name of Institution Last Exited:

Address:    City:    State:    Zip:

2. Institutional Number:

3. Type of Institution (check one):

Federal Penitentiary IDT (Mansfield) SAFP State Jail

State Penitentiary County Jail ISF

4. How many times have you been incarcerated?    What age were you first incarcerated?

5. List ALL charges, convictions, and other depositions received:

Offense Place Date Sentence

6. You are currently on (check one):

Probation Parole Federal Probation None of the above

7. Date you last entered prison/jail:    Date Released:

8. How long will you be on parole or probation?

9. Your parole/probation officer name:

Address:    City:    State:    Zip:

10. Are you presently residing in a halfway house? Yes No

Name of Halfway House:

Case Manager:    Phone Number:

Employment History

1. Are you working now? Yes No    Date Available for Work:

2. What was your last legal job before incarceration?

Job Title:    Employer:

Address:    City:    State:    Zip:

Duties Performed:

3. List all jobs that you worked in the institution:

4. List your preferences for employment:

1^st Preference:

2^nd Preference:

3^rd Preference:

5. List all your skills below:

6. List all machines, equipment, or tools you have experience with:

7. If you get a job where tools are needed, do you have any? Yes No Able to Purchase

8. Are you a Project RIO client? Yes No    RIO Case Manager:

9. What is your primary form of transportation? Bus Car Friends/Family

Education History

1. Highest Grade Completed:

1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4

2. Diploma: Yes No    GED: Yes No

3. What specialized job or vocational training programs have you participated in?

How long?    Did you receive a certificate? Yes No

Military History

1. Have you ever served in the military? Yes No

2. If yes, Branch:    Enlisted date:    Discharge date:

Type of discharge:

3. Have you registered with the selective services? Yes No

Family History

1. Marital Status:

Single Married Separated Divorced Widowed

2. Mate’s Name:    Date of Birth:

Address:    City:    State:    Zip:

3. List All Dependent Children:

Name: Sex: DOB: S.S. #:

Name: Sex: DOB: S.S. #:

Name: Sex: DOB: S.S. #:

Name: Sex: DOB: S.S. #:

Medical History

1. What is the state of your physical health?

Excellent Good Fair Poor Declining Improving

2. Are you disabled in any way? Yes No    If yes, what type of disability:

3. Have you ever been diagnosed with:

A. TB Yes No    If yes, when:

B. HIV/AIDS Yes No    If yes, when:

C. Mental Illness Yes No    If yes, when:

D. Hepatitis Yes No A B C    If yes, when:

4. Do you use alcoholic beverages? Yes No

5. Have you ever used drugs other than for medical purposes? Yes No

What How Long When

6. Do you attend AA/NA meetings? Yes No

7. Are you taking any prescription medications? Yes No

What Prescription For What Condition

8. What is your primary source of healthcare?

County Hospital (JPS) Private Insurance Self Pay Medicaid

Medicare VA Hospital Other

I hereby attest that I have answered all questions honestly and to the best of my ability.

Print Name:

Spiritual History

This information is voluntary and refusal to answer will NOT effect your eligibility for services.

1. Are you:

Christian Jewish Muslim Catholic Buddhist Other

2. If a Christian, what denomination are you?

3. Do you have a church home in Tarrant County? Yes No

Name of church:

Address:    City:    State:    Zip:

4. What is your pastor’s or spiritual leader’s name?

5. How often do you attend church or a place of worship?

6. What does your spirituality mean to you?

7. What do you like most about yourself?

8. What would you like to change about yourself?

9. Describe your childhood.

10. Would you like to speak to someone about your spirituality? Yes No

NEEDS

I. Physical Needs

Clothes

Food

Housing

Transportation for Job Interviews/Jobs

Medical/Dental Care

ID/Birth Certificate

Other (Please Explain)

II. Obtaining Benefits

Social Security

SSI

Food Stamps

Veteran’s Benefits

Other (Please Explain)

III. Social Needs

Support Group

Drug/Alcohol Treatment

Drug/Alcohol Support Group

Job Referrals

Individual Counseling

Other (Please Explain)

Please explain any other needs you might have.

Print Name: