Candidate Resources – Life Launch Inc.

Complete this form by answering as many of the sections that apply to your current circumstances.

Date

Date of Release:

Client Name:

SS#

Post Release Address:

Contact Number(s):

Race:

Black White Asian American Indian Hispanic Other

Probation:

Yes No

Probation Contact:

Do you have:

Birth Certificate Social Security Card State ID VA Driver’s License Suspended Revoked

Marital Status:

Married Divorce Separated Single

Spouse’s Name:

Do you have children?

Yes No

If Yes, how many?

Social Support Network (Name/Number): (ex. an AA sponsor, NA sponsor, etc.). Primary Contact Person: (Name/Number): (ex. a family member in case of emergency)

Are you a Veteran:

Yes No

Do you have a High School Diploma or GED?

Yes No

If No, are you interested in GED classes:

Yes No

Do you owe any fines/fees to any state agencies (ex. DMV, DCSE, etc.) If so, to whom?

Yes No

Do you have Housing?

Yes No

Transportation:?

Yes No

Do you need food and clothing assistance?

Yes No

Do you have Healthcare?

Yes No

Do you have a substance abuse problem?

Yes No

Were you working prior to being arrested?

Yes No

If yes, are you able to return to your previous employer?

Yes No

What were your sources of income prior to being arrested?

Employment SSI/Disability SNAP Other

While incarcerated, have you participated in any programs?

Yes No

If yes, which programs?

Do you have a resume?

Yes No

Would you like information or assistance on getting your rights restored?

Yes No

Skills/Experience

Warehouse Hospitality Janitorial Clerical Stage Hand Electrical Production HVAC Painting Plumbing Roofing Masonry Kitchen Audio/Visual Maintenance

Soft Skills

Active Listening Ability to work alone with minimal supervision Ability to work in groups Pays attention to detail Time Management Willingness Ability to follow instructions and learn new skills Interpersonal Communication Ability to peacefully resolve conflicts Problem Solving Skills

What skills and certifications do you have?

What are your plans upon release?

Other Re-Entry Services Needed:

Client Signature:

Case Manager Name:

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INITIAL CONTACT ASSESSMENT FORM FOR RETURNING CITIZENS

Section 1: Basic Information

Section 2: Immediate Needs
Please select any of the following areas where assistance is currently needed:

Housing Employment Substance Abuse Treatment Mental Health Services Legal Assistance Medical Needs Identification/Documentation (e.g., State ID, Social Security) Family Reunification Parenting Support Financial Literacy Educational Opportunities (GED, vocational training) Workforce Development Services

Other (please specify):

Section 3: Risk and Needs Assessment (Based on Carey Guides/OST Framework)

1. Substance Use Have you had any issues with alcohol or drugs in the past or currently?

Yes No

If yes, are you currently seeking treatment or open to treatment?

Yes No

2. Mental Health
Have you been diagnosed with or are you experiencing symptoms of any mental health condition (e.g., depression, anxiety)?

Yes No

If yes, are you currently seeking treatment or open to treatment?

Yes No

3. Criminal Thinking (Based on Carey Guides Tools)
Do you feel your thinking or behavior may lead to future legal problems?

Yes No

If yes, are you willing to explore tools to help change thinking patterns?

Yes No

4. Anger Management
Do you struggle with managing anger or emotions?

Yes No

Are you interested in tools or programs to help manage anger?

Yes No

5. Family/Social Network
Do you have a stable and supportive family or social network?

Yes No

Would you like assistance in building supportive relationships?

Yes No

6. Employment/Vocational Training
Are you currently employed?

Yes No

If no, are you looking for employment?

Yes No

Do you need help with job training or vocational skills?

Yes No

Section 4: Referral Needs

Based on the above answers, please check which services the client needs to be referred to:
Virginia CARES (Vocational Rehabilitation, Emergency Assistance, Legal Services)

Yes No

DARS (Department of Aging and Rehabilitation Services)

Yes No

Mental Health Resolutions LLC (Mental Health Services)

Yes No

Community Service Board (CSB)

Yes No

Workforce Development Services

Yes No

Substance Abuse Counseling

Yes No

Parenting Support Programs

Yes No

Financial Literacy Programs

Yes No

HRCAP (Hampton Roads Community Action Program)

Yes No

Pathways Home 3 (Housing Support, Employment Assistance)

Yes No

Section 5:
Notes & Next Steps 1. Assessor’s Notes:

2. Next Steps/Actions to Take:

Signature of Assessor:

Date: