Path To Wholeness Intake Application

Welcome to the Paths to Wholeness Intake Application. If you have a client that may benefit from utilizing our transitional services, please complete this form to help us understand your client's needs and how we can best support them on your journey. All information will be kept confidential and used solely for the purpose of assessing their eligibility.

Today's Date

Referring Agency Information

Referring Agency

Person Referring

Relationship to the client

Client Information

Client's first name

Client Middle Name, if applicable

Client's last name

If in shelter/program, list name

Client's Expected Release Date

Client's Social Security Number

Client's Date of Birth

Client's Last Address

Name of current/last correctional institution

How long was the applicant incarcerated?

What is the convicted offense?

Is there a case with Probation Pardon & Parole (PPP)?

Yes

No

If yes, please enter the Probation Pardon & Parole Officer's Name

Client's Relationship Status

Is the client pregnant?

Yes

No

If pregnant, how many months?

Does the client have children?

Yes

No

If yes, how many?

Client Demographic Information

What is the client's race?

What is the client's ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

What is the client's identified gender?

What is the client's primary language?

List any secondary languages, if applicable

Does the applicant have a Birth Certificate?

Yes

No

Does the applicant have a Social Security Card?

Yes

No

Does the applicant have a South Carolina State ID?

Yes

No

Emergency Contact Details

Emergency Contact Full Name

Emergency Contact Phone Number

Relationship to the client

Submission

I hereby certify that the information provided in this application is true and complete to the best of my knowledge.