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Intake/Support Form

This form is to be filled out by the CARE Coordinator or Freedom Project Staff. This is not meant to be filled out by the person receiving support.

Freedom Project supports "informal intakes" - all of these questions don’t need to be answered in order to submit this form. Please just provide the information that you have available to you. You can always come back and include more information at a later point. 

There are a few things we DO need though - a name (can be a nickname without a last name, as long as you use the same name when entering in more information about this person) You will also have to at least indicate which CARE Coordinator will be working with this person, which "project" the person is eligible for, and what "touch level" this person needs in their support.

If this person qualifies for a particular program (such as Credible Allies, which serves Black, Indigenous, and People of Color under age 30 with a connection to Seattle), please provide the demographic information that qualifies them for that program (such as birthdate, race, or zipcode), so that we can have the data needed to include them for those grant reports.


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This might not be the date that the form is being submitted - it could be the date that you first met this person, when someone you know reached out for support, or when you offered support as a CARE Coordinator.

How did you first get in contact with this person?



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Contact Info


Please enter numbers/symbols only - such as (555)555-555. Or leave blank if you don't know their number yet. Your form will not be able to submit if you enter any letters, such as "don't know".


"Situation Details" provides space where you can share more about what the person is going through - such as housing/employment situation or any specific disabling conditions that are important to know in supporting them. "Contact Person(s)" is where you can provide information on someone who is closely supporting this person, who might be working with you in coordinating support for this person, or who might be a "go-between" for you and the person (for example - a partner who is relaying information for someone incarcerated; or if their mother is providing and coordinating support for them).

Situation Details


This may include how permanent their housing is, who they're living/staying with, whether they are using any agency/government services for housing, etc.

This may include their employment status, employment plans, level of education, any training or experience they bring, etc.

This might include physical disabilities, developmental disabilities, mental disabilities, substance abuse conditions, etc.

Include here any barriers, strengths, or any other information that might be useful for this person's support.

Needs

What needs has this person expressed? When you check the need, a box will open up for you to provide additional details if available. There will also be a box that you can check if you have already met that need for this person. If a need has already been met, please provide the date that the need was met and whether any expenses were associated with the met need.

Provide details here on the specific needs of the individual, if needed or relevant.



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Examples: seeking specific resources that support folks who identify as LGBTQAI+, survivors of domestic violence, support related to leaving a gang, etc.

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Contact Person

Please provide someone as an emergency contact should we be unable to reach you.















Demographics


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Options may include (cisgender or trans) male, (cisgender or trans) female, nonbinary, gender fluid, two-spirit, intersex, etc.

If they use gender pronouns not included in the list above, please identify those here.

Please enter numbers only or leave blank if unknown. Your form will not be able to submit if you enter any letters, such as "don't know".
Program/Funding Eligibility
Certain aspects of this person's situation may qualify them for funding we have for specific populations, locations, etc. This section may change depending on the funding we have available. Please check each situation that applies to this person.
This impacts people who were previously charged and convicted under the drug possession statute RCW 69.50.4013(1). Can result in release, shortened sentence, or a stricken or shortened probation period.
Beyond the Blindfold of Justice - Legal Intake Questions

If you do not have this information yet, please use the CARE Coordinator report form to provide updated information or contact Felicia/Champion regarding next steps for this individual.

Beyond the Blindfold of Justice - Legal Intake

Please follow up with case information through the CARE Coordinator report form or contact Felicia/Champion regarding next steps for this individual.

Legal Matter



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Ancillary Issues

These are any issues that if the "Blake" decision is expunged/vacated would be affected as well.

Other Parties


If yes, please provide name and any contact information.

If yes, please provide name(s).
Toolkits provide information on the Blake case decision and processes for getting conviction vacated, expunged record, refunded LFOs, etc.

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Credible Allies is a specific program for Black, Indigenous, and People of Color under the age of 30. Safe Return is for all other folks reentering in the Puget Sound/Western Washington area. Freedom Project East is for people reentering in Eastern Washington and the Spokane area.