Basic Needs Assessment
Rural Reentry Ministry helps Christian felons return from prison and reintegrate into rural communities through biblical discipleship and mentoring services.
Email address *
Name *
Phone Number *
People in your household: (Name, Age, Gender, Relationship)
Documentation
Do you need any of the following?
Employment
Are you currently employed?
Name and Phone of employer? (if employed)
If seeking, do you need help with?
List any members of your household that are employed and where:
List any other income sources and amount: (SSI, workman's comp, child support, etc.)
Medical/Mental
Do you have health insurance?
Please list any medical or mental conditions, especially those currently being treated by a physician or prescription.
Are you working with any agency on your health or mental issues?
If yes, include any doctor’s office, non-profit, religious group, or governmental agency:
Do you need information on an income-based medical clinic?
Do you need an emergency dental work referral from HCC?
Do you have a substance abuse history?
If yes, what was your drug of choice and the last date of use?
Have you ever been or are you in:
Support
Please list all members of your household besides yourself.
Do you need emergency help with:
Have you received assistance from other churches and organizations: (when, where, amount)
Do you attend a local church?
If yes, which one?
INTERNAL: Referred by *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy