Post Release Application Form
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Case Manager
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Dakota Jones
Dylan Horn
Adam Jolly
Stedmund Anthony
Laesha Brewer
Ivan I
Travis Spencer
Holland “Ricky” White
Elmo Golden
Jack Brewer
Balamurugan
Alexandra Caro Campana
Clouie Lorono
test account
Paula Mathis
Andra Robinson
Jose J
Carl Pugh
Junior Lysius
David Burke
Albert Yaghy
Stephen Testa
Edward Castleton
Bernard Pratt
Mitchell R Brown
Anthony Sayer
David Lowe
Jennifer Blackburn
Darryl Ellis
Jared Brewer
Cortney brewer
Michael Newsome
Polina Malakhova
Karen West
Jillian
Monisha Arjunan
Idrissa Ibrahim Mussa
test prema
Peyton Hankins
Vernon Ripley
Anil
Troy Martin
Brian Vause
Test Priyanga
Emiliano lamothe
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First Name
Last Name
Date of application
EC
Date of Birth
Age
Email
Email Verified Successfully
Phone
Phone Number Verified Successfully
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Section 1
Street
County
State
City
Zip Code
SSN (Last 4 Digit)
Are you currently, or will you upon release, be considered the biological, custodial, legal, adoptive, foster or stepfather, grandfather, non-relative male, or male family member serving in a Father role of a child or children 17 y/o or younger, living in the state of Florida?
Yes
No
Marital Status
Married
Un Married
Divorced
Widow
Cohabiting
Did you grow up with an active father?
Yes
No
Did your father consistently tell you he loved you while you were growing up?
Yes
No
Number of Children (Total number of children aged 17 & under)
Child Type
Biological Children
Nephews
Great Nephews
Stepchildren
Nieces
Great Nieces
Grandchildren
Great Grandchildren
God Children
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Have you ever lived in residential re-entry, recovery, or halfway housing, or are you currently residing in any of these types of facilities?
Yes
No
If yes, where?
Where do you live now? Legal Address
Legal Street
Legal County
Legal State
Legal City
Legal Zip Code
What is your source of income?
SSI
SSD
SNAP
TANF
Employed
UnEmployed
Are you in contact with your children?
Yes
No
Do you want to be in contact with your children?
Yes
No
With whom do your minor children currently reside?
Unsure
Guardian Information
Guardian Name
Guardian Street
Guardian County
Guardian City
Guardian State
Guardian Zip
Education level of Adult children (circle all that apply):
Unsure
Select Child Education
High School Diploma
High School Dropout
GED
Trade
Some College
College Graduate
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Do you have an open Child Support case?
UnSure
Yes
No
Have you ever been arrested for a sex crime or Arson?
Yes
No
Were you convicted of a crime as a youth offender?
Yes
No
Have you ever been convicted of a gun-related crime?
Yes
No
Have you been, or are you currently, affiliated with a gang?
Yes
No
Probation/Parole?
Yes
No
P.O. Start Date
P.O. End Date
P.O Name
P.O Phone Number
Section 2
Are there any court orders, child or family visitation restrictions?
Yes
No
If so, please explain :
Do you have any abuse/neglect cases with the Department of Children and Families?
Yes
No
If so, please explain :
Emergency Contact Details
Emergency Contact Name
Emergency Street
Emergency County
Emergency Email
Emergency State
Emergency City
Emergency Zip Code
Emergency Phone
Are you currently In contact with any of your family?
Yes
No
If so, please explain :
What is the Frequency and method of communication with family members?
No contact
Daily
Weekly
Bi-Weekly
Monthly
Yearly
Method of contact with the family?
Letter
Mail
Phone
Do you currently receive visits from family? (In person visitation)
Yes
No
If Yes, please write
Are you currently taking any prescription medications?
Yes
No
Choose Not to Disclose
If Yes, please write
Have you been addicted to illegal substances in the past, or are you currently struggling with addiction?
Yes
No
Choose Not to Disclose
If yes, write the Date of last use and Drug of Choice:
Have you experienced relapse?
Yes
No
Choose Not to Disclose
If yes, write the Date of last use and Drug of Choice:
Do you have any compulsive behaviors?
Yes
No
Choose Not to Disclose
What difficulties have been caused by your addictions?
Section 3
Have you ever received a DUI?
Yes
No
If so, How many ?
Do you struggle with following rulesor respecting authority?
Yes
No
Do you have any biases or prejudices against certain groups or races?
Yes
No
Have you experienced or are you currently experiencing suicidal thoughts?
Yes
No
If yes, have you thought of a plan?
If yes, do you agree to enter into a plan of action/safety if needed?
Yes
No
Currently employed?
Yes
No
Employer Name
Employer Address
Employer County
Employer State
Employer City
Employer Zip Code
Supervisor's Name
Supervisor's Phone No
Section 4
Enrolled in college/University?
Yes
No
If yes, Days in Attendance:
Have you experienced relapse?
Yes
No
Choose Not to Disclose
If so, please explain :
Does your immediate family currently receive government assistance?
SNAP
SSI
SSD
Medicaid
TANF
Other
No
Unsure
Does your immediate family need additional assistance with food, clothing, or shelter?
Unsure
Yes
No
Do you feel your immediate family would participate in parenting class and other family focused development programs?
UnSure
Yes
No
Are you currently enrolled in Continuum of Care (COC) Programming?
UnSure
Yes
No
Have you ever given your life to Christ?
Yes
No
If so, date:
Have you ever been baptized?
Yes
No
If so, date:
Do you have a testimony?
Yes
No
If so, what is your testimony?
Are you a Veteran?
Yes
No
If yes, branch
USAF
USARMY
USCG
USMC
USNAVY
Section 5
High School
Yes
No
Drop-out
GED
Yes
No
Inprogress
College
Yes
No
Drop-out
If yes, completion date:
If yes, completion date:
If yes, completion date:
Professional Skills:
Landscaping
Painting
Construction
Debris/Waste Removal
Carpentry
Chef
Driver
Other
If other, what is your Professional Skill?
Degrees/Certifications/Licenses:
Do you have any sports history?
Yes
No
If so, please write:
Do you have any arts and entertainment history?
Yes
No
If so, please write:
Have you been incarcerated multiple times?
Yes
No
Unsure
How many times:
Have any of your family members been incarcerated?
Yes
No
Unsure
If so, please explain:
Do you need help with the following ?
Cell Phone
Shoes
Clothing
Food
Shelter
Other
If other need Please Explain:
Felony convictions ?
Yes
No
If so, please explain:
Section 6
Do you own a car?
Yes
No
Do you have a current driver's license?
Yes
No
Do you have a Bank Account?
Yes
No
Do you have access to reliable transportation?
Yes
No
Are you currently enrolled in post release program?
Yes
No
Name of Program
Contact Person
Phone
Email
Have you ever participated in anger management, mental health, substance abuse, or addiction treatment?
Yes
No
Choose Not to Disclose
If so, please explain:
Preferred Language for Speaking and Writing:
English
Portuguese
Spanish
Creole
Other
If other, please write the Language:
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