Returning Citizen Intake

The Comeback Initiative Network · Reentry & Workforce Development

Confidential · Staff Use Only

1. Personal Information

Basic contact and identification details

Full Legal Name*

Date of Birth

Phone Number*

Email Address

Current Address

City

State

ZIP

Emergency Contact Name

Emergency Contact Phone

Relationship

2. Incarceration History

Details about prior incarceration and release

Facility / Institution Name

Release Date*

Total Time Served

Offense Type / Category

Brief Description of Charges (Optional — for case planning purposes)

3. Current Supervision Status

Probation, parole, or community control details

Still On Supervision? (Probation / Parole / Community Control)

4. Fines, Fees & Restitution

Outstanding court-ordered financial obligations

Do you have outstanding fines or fees?

Do you owe restitution?

5. Current Living Situation

Housing, employment, and education

Housing Situation

Employment Status

Highest Education Level

6. Barriers & Support Needs

Select all that apply

Barriers You Are Currently Facing

Support Services You Are Requesting

7. Goals & Aspirations

Tell us where you want to go

Short-Term Goals (Next 30–90 days)

Long-Term Goals (6 months – 2 years)

8. How Did You Find Us?

How did you hear about TCBIN?

Prior Contact with TCBIN?

Anything Else You'd Like Us to Know

Consent & Confidentiality

By submitting this form, I consent to share the information above with The Comeback Initiative Network (TCBIN) for the purpose of receiving reentry support services. I understand this information is confidential and will not be shared without my consent except as required by law.