Participant Information

First Name *

Last Name *

AKA (Alias):

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

City

State

Zip Code

Residency Status

I Am A Citizen/Legal Resident

I Am Not A Citizen/Legal Resident

Phone Number *

Today's Date: (MM-DD-YYYY) * +

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? *

Race *

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

What are your greatest concerns and needs at this time (check all that apply) *

Education and 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?

Do You Have Proof Of Income/Verification Of Benefits? *

Yes

No

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 Ever Been Convicted And Served Time In A California State Prison? *

Yes

No

Unsure

If Yes (name of institution) If Yes (name of institution)

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

Are You Currently On Parole? *

Yes

No

For verification purposes, please provide your CDCR# or Parole/Probation Officer's name and contact information. ( enter "n/a" if you have not been convicted and sentenced to prison in the State of California) *

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

Specify How You Were Referred To The Program? *

Name of Person or Agency That Referred You *

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 State ID/DL	SS Card	Birth Certificate
TB Clearance (Last 12 Months)	In Progress To Obtain Documents

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

Currently incarcerated	Zero (0) days to 2 months ago
3 months-6 months ago	7 month -12 months ago
13 - 24 months ago	25 months - 35 months ago
3-5 years	6-10years
11 or more years ago