Please provide what needs you are currently experiencing (for example: clothing, employment, transportation, security deposit or first month’s rent, utility bills, tools/equipment for my current job, back rent, furniture, home furnishings etc.)
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Name
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First Name
Last Name
Phone
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(###)
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Are you able to text from your phone?
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Email: (You will need to create an email if you don’t have one so we can communicate with you further.)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
County:
Date of Birth
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MM
DD
YYYY
Who referred you to Here to Help or how did you learn of our ability to assist?
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If you have children, please list their ages:
When were you released from prison? (Not for a parole violation but released for your original prison sentence) NOTE: STOP HERE IF YOU ARE NOT COMING BACK FROM PRISON. WE ONLY WORK WITH RETURNING CITIZENS.
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How many years were you in prison?
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What is the full name and office phone number (NOT cell phone number) of your parole agent or Federal Probation Officer? I have to have this information to proceed as I will make an initial call to your Agent.
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What is your MDOC Inmate Number or Federal Prisoner number? If your prison sentence was out of state then please indicate what state and your prison number.
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Is any other individual or other agency or organization assisting you with your reentry? If so, please provide his/her name and phone number and what their job is and what they are doing to help you.
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Please explain your current living situation. Are you living in a group home/transitional house or with family members etc. or have have you rented an apartment or house?
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When did you move into your current living situation?
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If you are not living in your own place what are your plans as far as your future living situation and is anyone helping you find a place?
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Do you have any income at the present time? If so, please provide the sources of all your monthly income. For example, wages or disability assistance or Social Security or food assistance etc.
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If no income at present, please answer how you anticipate receiving income in the future and from what sources.
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If you have an income now, please provide the amount of your net income (after taxes, deductions, garnishments etc.) you earn per month whether it be from wages or disability or Social Security etc. Again, this is your take home pay after all deductions are made from your source of income.
Have you had prior training for a job skill (for example car repair, plumbing, HVAC, electrician, welding, masonry etc.) and, if so, for what skill?
If you have not had any training, please state the name of any particular employment trade/skill you are interested in learning? If no interest, answer “Not applicable."
If you are working, please provide the name of the company where you are working, when you began working there, how many hours you work per week and your hourly pay.
If you are employed at your job through a staffing agency then please answer: the name of the staffing company and whether you have been told, by the company you are working at, that you may be hired in as a permanent employee and, if so, when that will be.
If you are NOT working, please answer what you are currently doing or planning to do to obtain employment or job training and who, if anyone, may be assisting you. This is a very important answer so please be specific.
If you are disabled and cannot work, please answer whether you have applied for benefits and the status of that request if any.
If you currently have monthly bills, please list the names of your monthly bills and the specific amounts for of ALL of these monthly costs.
Additional Information: If there is further information that you would like us to be aware of then tell us everything else you want us to know, including any of your current needs or concerns.
Please list which of the following you need assistance with as we can provide information to help you: Obtaining a Phone; Obtaining governmental documents (State ID or Driver's License or Social Security card etc.); Employment and Job Training; Transportation, Finding Housing; Public Benefits (for example: food benefits, disability payments etc.); Counseling or Substance Abuse Treatment
