Welcome to Phoenix Pathway Reentry Intake Form

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We are dedicated to facilitating your successful reintegration into the community. Please share as much information as you are comfortable providing. Rest assured that your details will remain confidential and will be utilized exclusively to customize your reintegration plan.

Full Name:____________________________

DOB:__________      Age:_____

Gender:___M____F____or ____Trangender

Emergency Contact __________________

Name of Correctional Facility______________________

Date of Release/ Expected Release Date________________

Length of Incarceration__________

Conviction State____________________

Conviction County__________________

Incarceration Conviction______________________

Parole/ Probation Status (Y/N)_________________

Do you have any chronic medical condition? (e.g. diabetes, hypertenison, asthma)☐ Yes ☐ No

If yes, please specify:______________

Are you currently taking any medications?☐ Yes ☐ No

If yes, please list medication and doses:

_______________________________________________________________

 Have you ever been diagnosed with a mental health condition? ☐ Yes ☐ No 

If yes, please specify_________________________

 Are you currently receiving mental health treatment or counseling? ☐ Yes ☐ No 

 Do you have any history of substance use or addiction?
☐ Yes ☐ No 

  I understand that the information I provide will be used to support my health and well-being as part of Phoenix Pathways’ reentry coaching services. I consent to the collection and use of this information in accordance with privacy laws and policies. 

Disclaimer

Phoenix Pathways provides personalized reentry coaching and support services designed to assist individuals transitioning from incarceration. Our services are intended to offer guidance, resources, and encouragement but do not constitute legal, medical, or mental health advice. While we strive to connect clients with appropriate professionals and community resources, Phoenix Pathways is not a licensed provider of legal, medical, or clinical services.

Clients are encouraged to seek professional advice for specific legal, medical, or mental health concerns. Phoenix Pathways does not guarantee outcomes and is not responsible for any decisions or actions taken based on the coaching or information provided.

By engaging with Phoenix Pathways, you acknowledge and accept these terms.