Participant Information

First Name *

Last Name *

AKA (Alias):

Current Address (If Experiencing Forms of Homelessness, Write "Homeless")

City

State

Zip Code

Residency Status *

Citizen/Legal Resident

Undocumented

Phone Number *

Date of Birth (MM-DD-YYYY) * +

Age *

Social Security Number (Last 4) *

Email Address

What Is Your Gender Identity? *

Male

Female

Transgender Male

Transgender Female

Genderqueer, Neither Exclusively Male nor Female

Non-Conforming

Additional Gender Category or Other, Please Specify Additional Gender Category or Other, Please Specify

What Is Your Sexual Orientation ? (Check All That Apply) *

Ethnicity *

Hispanic

Not Hispanic

Race *

Do You Have The Following Identifying Documents (Check All That Apply): *

Education/ Financial Resources

Are You Currently A Student? *

Yes

No

Grade of Education Last Completed *

What Is Your Income Source? *

Total Monthly Income (If no income write "0") *

If Employed, Where?

Housing History

Current Housing Status *

If Other, Please Explain:

Do You Currently Pay Rent? *

Yes

No

How Much Rent Do You Pay Per Month? *

Have You Ever Been Evicted? *

Yes

No

Unsure

Have You Ever Lived In A Transitional Living Facility Before? *

Yes

No

What Transitional Living Facility Have You Lived In Before?

Justice Involvement (Legal History)

Have You Received A Criminal Conviction? (A criminal conviction is defined as found guilty of a crime.) *

Yes

No

Unsure

If "Yes", How Long Ago Did You Receive A Criminal Conviction? *

Have you ever been convicted and sentenced to Prison in the State of California? *

Yes

No

Unsure

If Yes, How Long Ago Were You Released From CA State Prison? *

Are You Currently On Parole? *

Yes

No

Are You Currently On Probation? *

Yes

No

If Yes To Probation, Which Form of Probation Are You Currently On? (If NO, select N/A) *

Mental Health Wellness

Have You Ever Used Substances (alcohol or drugs)? *

Yes

No

Unsure

Do You Currently Use Substances (alcohol or drugs)? *

Yes

No

Unsure

If Yes, What Substances Do You Currently Use?

Are You Currently Engaged or Interested In Recovery Support Services? *

Yes

No

Unsure

Are You Currently Engaged In Any Outpatient Or Mental Health Services? *

Yes

No

Unsure

Are You Interested In Engaging In Any Outpatient Or Mental Health Services? *

Yes

No

Unsure

Have You Ever Received A Mental Health Diagnoses? *

Yes

No

Unsure

Reference of Support

Do You Currently Have A Case Manager or Support Reference? *

Yes

No

Name of Reference

Telephone Number of Reference

Agency Name:

Emergency Contact

Name of Emergency Contact

Relationship to Emergency Contact

Telephone Number of Emergency Contact

Acknowledgement Clause

BY CLICKING, I affirm, I have had justice involvement with California State Prisons. I hereby acknowledge that I have completely read, understand, and certify that all the information and answers to questions are complete, true, and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts in the Reclaiming Innocence application may disqualify me from continuing to participate in the AMAAD Departmental Programs and render this application void. *

I hereby acknowledge that I have completely read, understand, and certify.

Valid ID/DL	CA ID/DL	SS Card
Birth Certificate	Permanent Resident ID	TB Clearance (Last 12 Months)
Proof of Income/Verification of Benefits	DD214 (For Veterans)	Certification of Homelessness
Disability Certification	In Progress To Obtain Documents

Work/Employment	Unemployment
Disability/SSI	Family/Friends
General Relief (GR)	Veteran's Benefits
Other Other

1-3 months	3-6 months
9-12 months	1 year
2 years	3-5 years
5-7 years	7-10 years
10+ years

1-3 months	3-6 months
9-12 months	1 year
2 years	3-5 years
5-7 years	7-10 years
10+ years	N/A