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Pathway Home 2 Participant Screener Form
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* Indicates required question
Who is completing this Screener
*
Choose
Potential Client
Reset
MER
LRC
SOURCE
Prison/Jail Case manager
PO Officer
Other
Current or most recently released facility
*
Your answer
Do you have pending charges
*
Yes
No
Eligibility requirements: Will you be released within the next 180 days to New Hanover or Pender County
*
Yes
No
Where is your county of return?
*
Your answer
Release Date
*
Your answer
OPUS Number:
*
Your answer
First Name
*
Your answer
Middle Name
Your answer
Last Name
*
Your answer
Mailing Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Case Manager (if currently incarcerated)
*
Your answer
Case Manager phone number
*
Your answer
Case Manager email
*
Your answer
Sex assigned at birth
Your answer
Gender Identity
*
Your answer
What are your preferred pronouns? (she/her,he/him,they/them,she/they,he/they,all,ze/zir)
Your answer
Birthday (MMDDYYYY)
*
MM
/
DD
/
YYYY
Social Security #
*
Your answer
Birthplace (City, State)
*
Your answer
Are you a U.S. Citizen?
*
Yes
No
Are you registered for selective service?
*
Yes
No
Unsure
Are you a veteran?
*
Yes
no
If you are a veteran, in which branch did you serve?
Your answer
Are you currently incarcerated?
*
Yes
No
Are you currently on work release?
*
Yes
No
Do you have a disability?
*
Yes
No
Prefer not to say
If you answered yes to having a disability, please select the appropriate box below
Physical/Chronic Health Conditions
Vision-related Disability
Physical Mobility Impairment
Cognitive/Intellectual Disability
Hearing Related Disability
Mental/Psychiatric
Participant did not disclose type of disability
Learning Disability
Other:
Ethnicity
*
Hispanic
Non-Hispanic/Latino
Prefer not to say
Race (Select all that apply)
*
Black/African American
White
Hispanic/Latino
American Indian/Alaskan Native
Asian
Prefer not to Say
Other
Required
Highest Level of Education (Select One)
*
9th Grade
10th Grade
11th Grade
12th Grade
Associate Degree (2 Year College Degree)
Bachelor's Degree (4 Year College Degree)
Other:
Required
Have you received one of the following?
*
GED
High School Diploma
Neither
Are you interested in continuing education?
*
Yes
No
Participants Interest (Please check all that apply):
*
Job training
Job placement
Transportation Costs
Medical Services
Required
I am interested in receiving info on classes about:
*
High School Equivalency
PC Troubleshooting & Repair
Network Cable Installation & Telecommunications
Masonry
Electricity and Electronics
Light Construction
ESL
Cognitive Behavioral Intervention
Truck Driving Training
Serve Safe
Forklift Certification
Participant is not interested in receiving information on classes
Other:
Required
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