Release Referral

First Name*
Middle Name
Last Name*
Institution ID:*	Identification number assigned by the institution.
Gender*
Date of Birth*	(MM/DD/YYYY)
Date of Release*	(MM/DD/YYYY)
Release Date Confirmation*	Release Date Confirmation Yes No Is the release date confirmed? If not, please describe below why the date is pending.
Pending release explanation	Please briefly describe why the release date is subject to change.
Has the individual been previously incarcerated for a sexual offense?*	Has the individual been previously incarcerated for a sexual offense? Yes No
Is the individual currently incarcerated for a sexual offense?*	Is the individual currently incarcerated for a sexual offense? Yes No Answer "No" if the individual is currently incarcerated for a non-sexual offense even if there is a past sexual offense on their record.
Releasing Facility*
MTC Release Type*	MTC Release Type State Civil n/a
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 mobility issues.
Has the individual served in the military at any time?*	Has the individual served in the military at any time? Yes No
Has MassHealth coverage been activated?*	Has MassHealth coverage been activated? Yes No Unknown
With which BHJI organization have services been initiated.*
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*	BRN only accepts clients who have confirmed housing prior to release.
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:
	I forgot my private link.

A confirmation email from BRN will indicate receipt of this form.