Nolef Turns · Nolef Turns Re-Entry Intake Application

Please read this first before submitting this application.*

This application is for individuals who have been released from a Virginia Department of Corrections or Federal Bureau of Prisons facility in the last year.

If you are currently incarcerated in a Virginia DOC or BOP facility (or are completing on behalf of an individual who is incarcerated), please complete the Pre-Release intake application.

If you only need assistance with voter registration, restoration of rights, or miscellaneous services, please complete the Special Programs application.

For referrals, please complete a Community Partner application prior to submitting your first referral application.

I accept the Terms and Conditions.

*

Yes

Name

*

Prefix

First Name

Last Name

Suffix

Race/Ethnicity

*

White or Caucasian

Black or African-American

Asian

American Indian, Alaska Native, Native Hawaiian or other Pacific Islander

Multi-Ethnic

Other

Gender

*

Female

Male

Non-binary/Non-conforming

Other

Phone

*

Email

Please provide an email for professional contacts.

Verify Email

Date of Birth

*

(mm/dd/yyyy)

Social Security Number

*

###-##-####

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Referred by

*

Medicaid/Insurance Information

Please list your identification number found on your Medicaid or Medicaid HMO card. Leave blank if you do not have Medicaid.

Virginia ID Number

Please list your identification number found on your state-issued ID or license with expiration and issue dates. Leave blank if you do not have a state issued ID.

Issue Date

*

Please list the issue date on your state issued ID

Expiration Date

*

Please list the expiration date on your state issued ID

Resume

Please list your most recent resume, if available.

Have your civil rights been restored?

*

Yes

No

Are you interested in having your civil/voting rights been restored?

*

Yes

No

Please list your past felony conviction(s), date of conviction and court

*

Please accurately list all city, county, and/or federal court(s) of conviction, along with all felony charges. If you do not list all convictions, services cannot be provided.

Release Date

*

Please list your release date and from which facility in the past year. If you were sentenced to probation, please list conviction date.

Facility Released From

Are you on parole/probation?

*

Yes

No

If yes, please list your officer's name, locality and expected release date?

*

Do you have pending charges, other than minor traffic infractions?

*

Yes

No

List pending charges and court, if applicable

*

Please accurately list any pending charges along with city, county and/or federal courts where pending. List upcoming court dates, if applicable.

Are you listed on the sex offender registry or required to register?

*

Yes

No

What is your highest level of education?

*

Annual Income*

*

Do you have any income?

*

Please include all income sources (employment, TANF, SSI, retirement, pension, savings, etc.)

Yes

No

Please select your current income source(s)

*

Please select all current sources of income. This will better determine placement and eligibility in certain programs.

Employment (including self employment)

Unemployment

Supplemental Security Income (SSI)

Retirement/Pension/Social Security Benefits

TANF

Stipend From Other Programming

Other

Please explain

*

Are you currently employed?

*

Yes

No

Organization/Employer

*

Please list complete address and position.

Work History

*

Please list brief work experience and/or skills. List dates of employment, supervisor's name, and specific location. Include apprenticeship, trade certifications and volunteer work.

Do you have a valid driver's license?

*

Yes

No

Do you have reliable transportation?

Yes

No

If not, please list any restrictions to obtaining your license.

*

Please briefly list the service(s) you need assistance with. Please note that all information shared with our organization is in complete confidentiality and the information obtained will be used to assist in your success.

*

Please be specific.

Please list other service providers you have explored or are receiving services from, if applicable.

(CSB, CPS, Stabilization, Judiciary, DSS or other mental health (please list names and contact information))

Signature (TYPE YOUR FULL NAME)

*

By signing this form, you give permission to communicate with others on your behalf regarding the services requested. You acknowledge that Nolef Turns does not offer legal advice and we cannot guarantee results for each participant.

Please send completed application, consent forms and a copy of your resume (if available) to:

Nolef Turns Inc.

Attn: Client Intake Application

211 N. 18th Street

Richmond, VA 23223-6905

Online at www.nolefturns.org

or email to:

info@nolefturns.org

Please consider becoming a member or making a tax-deductible donation to support our mission.