Release Questionnaire

First Name*
Middle Name
Last Name*
Gender*
Date of Birth*	(MM/DD/YYYY)
Date of Release*	(MM/DD/YYYY)
Releasing Facility*
Who will transport the individual from the releasing facility?
Is the individual under supervision?*	Is the individual under supervision? Probation Parole None Unknown
Court of Jurisdiction*
Does the individual have a GPS requirement?*	Does the individual have a GPS requirement? Yes No Unknown
Sex Offender Registration Board (SORB) designation*	Sex Offender Registration Board (SORB) designation 0 1 2 3 Unknown n/a
Describe any health issues (non-mental).
Describe any mental health issues.
Describe any mobility issues.
Has Standard (not Basic) MassHealth coverage been activated?*	Has Standard (not Basic) MassHealth coverage been activated? Yes No Unknown
Does the individual have their birth certificate*	Does the individual have their birth certificate Yes No Unknown
Does the individual have a social security card?*	Does the individual have a social security card? Yes No Unknown
Does the individual have a valid Massachusetts ID?*	Does the individual have a valid Massachusetts ID? Yes No Unknown
Does the individual have property to be acquired upon release?	Does the individual have property to be acquired upon release? Yes No Unknown
Massachusetts housing contact name*
Massachusetts housing address*
Massachusetts housing contact phone*
If leaving Massachusetts, what travel arrangements have been secured?
Emergency contact (name and phone)
Name of party completing questionnaire.*
Email of party completing questionnaire*
Name of organization completing questionnaire.*
Special Notes: