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One Stop Shop InTAKE FORM
Intake Application
Please fill out the following application. Once you have completed the application, you will be redirected to the SWAG curriculum for registration.
First Name
Middle Initial
Last Name
Are you homeless?
*
Yes
No
Mailing Address (if currently experiencing homelessness, enter N/A below)
City
State
County
Zip Code
Phone
Email
Gender
Choose an option
What are your pronouns?
Choose an option
Race (Check all that apply)
Native American
Asian
Black
White
Latino
Middle Eastern
Other
Birth Country
Primary Language
English
Spanish
Other
Age
Citizenship
Choose an option
Highest Level of Education Completed
Choose an option
Marital Status
Choose an option
Access to Internet (Check all that apply)
Phone
Pad/Tablet
Home Computer
Work
Library
Current Employment
Choose an option
Primary Transportation
Choose an option
Level of Income
Choose an option
Current Barriers (Check all that apply).
Criminal Record
Lack of Career Information
Lack of Education
Low Motivation
Disability
Health Challenges
Low Job Skills
Lack of Access to Job Training
Homelessness
Language Barrier
Re-entry Status
Choose an option
Personal Documentation (Check all documents that you have)
Texas ID/US Government ID
Birth Certificate
Social Security Card
None of the above
What was the length of your incarceration?
Choose an option
How many times have you been incarcerated?
Choose an option
What support sevices re you most in need of?
Housing
Employment
Education
State Issue ID
Other
Do you have a community support system? (ie. family, significant other, etc.)
*
Yes
No
Do you have an active case with Child Protective Services (CPS)?
*
Yes
No
Have you ever had a plan for your reentry?
*
Yes
No
Would you be willing to share the nature of your conviction? (Optional)
Submit
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