Reentry Support Services Intake Form — Form Fields
This nonprofit template includes 10 fields. Intake form for individuals recently released from incarceration seeking reentry support services. Free to customize and use on ZenBuild.
First Name (text, required)
Last Name (text, required)
Phone Number (text, required)
Email Address (email, optional)
Date of Release (text, required)
County or City Currently Residing In (text, required)
Services Needed (checkboxes, required) — options: Housing assistance, Employment support, ID/documents help, Substance use treatment, Mental health counseling, Family reunification, Transportation, Financial literacy
Do you have stable housing currently? (multiple choice, required) — options: Yes, No – staying temporarily, No – homeless
Do you have valid government-issued ID? (multiple choice, required) — options: Yes, No – need assistance
Additional Context or Immediate Concerns (long text, optional)
