{"id":657,"date":"2022-06-22T15:50:48","date_gmt":"2022-06-22T19:50:48","guid":{"rendered":"https:\/\/baystatereentrynetwork.org\/?page_id=657"},"modified":"2025-08-07T09:59:15","modified_gmt":"2025-08-07T13:59:15","slug":"release-questionnaire","status":"publish","type":"page","link":"https:\/\/baystatereentrynetwork.org\/index.php\/release-questionnaire\/","title":{"rendered":"Release Questionnaire"},"content":{"rendered":"<div class=\"wrap pdb-signup pdb-instance-2\" >\n\n    <form method=\"post\" enctype=\"multipart\/form-data\"  autocomplete=\"off\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/657\" ><input name=\"action\" type=\"hidden\" value=\"signup\" \/>\n\n<input name=\"subsource\" type=\"hidden\" value=\"participants-database\" \/>\n\n<input name=\"shortcode_page\" type=\"hidden\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/657\" \/>\n\n<input name=\"thanks_page\" type=\"hidden\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/657\" \/>\n\n<input name=\"instance_index\" type=\"hidden\" value=\"2\" \/>\n\n<input name=\"pdb_data_keys\" type=\"hidden\" value=\"1.23.2.35.25.26.85.86.87.88.64.47.48.30.49.31.32.52.83.53.81.54.55.56.57.67.58.68.59.60.61.62.63.80\" \/>\n\n<input name=\"session_hash\" type=\"hidden\" value=\"340a5da688\" \/>\n\n    <table class=\"form-table pdb-signup\">\n\n      \n      <tbody class=\"field-group field-group-main\">\n        \n                \n        \n        <tr class=\"text-line first_name-input-group\">\n\n          <th for=\"pdb-first_name-2\">First Name<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"first_name\" id=\"pdb-first_name-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line middle_name_initial-input-group\">\n\n          <th for=\"pdb-middle_name_initial-2\">Middle Name<\/th>\n\n          <td>\n\n            <input name=\"middle_name_initial\" id=\"pdb-middle_name_initial-2\" class=\" regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line last_name-input-group\">\n\n          <th for=\"pdb-last_name-2\">Last Name<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"last_name\" id=\"pdb-last_name-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"dropdown gender-input-group\">\n\n          <th for=\"pdb-gender-2\">Gender<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <select name=\"gender\" id=\"pdb-gender-2\" class=\"required-field\">\n<option value=\"\" selected=\"selected\">&nbsp;<\/option>\n<option value=\"Male (CIS)\">Male (CIS)<\/option>\n<option value=\"Female (CIS)\">Female (CIS)<\/option>\n<option value=\"Male (trans)\">Male (trans)<\/option>\n<option value=\"Female (trans)\">Female (trans)<\/option>\n<option value=\"prefer not to say\">prefer not to say<\/option>\n<\/select>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"date dob-input-group\">\n\n          <th for=\"pdb-dob-2\">Date of Birth<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"dob\" id=\"pdb-dob-2\" class=\"required-field regular-text date_field\" type=\"text\" value=\"\" \/>\n\n                        <span class=\"helptext\">(MM\/DD\/YYYY)<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"date date_of_release-input-group\">\n\n          <th for=\"pdb-date_of_release-2\">Date of Release<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"date_of_release\" id=\"pdb-date_of_release-2\" class=\"required-field regular-text date_field\" type=\"text\" value=\"\" \/>\n\n                        <span class=\"helptext\">(MM\/DD\/YYYY)<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio release_date_confirmation-input-group\">\n\n          <th for=\"pdb-release_date_confirmation-2\">Release Date Confirmation<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Release Date Confirmation<\/legend>\n<label class=\"required-field\" for=\"pdb-release_date_confirmation-yes-2\">\n<input name=\"release_date_confirmation\" id=\"pdb-release_date_confirmation-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-release_date_confirmation-no-2\">\n<input name=\"release_date_confirmation\" id=\"pdb-release_date_confirmation-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        <span class=\"helptext\">Is the release date confirmed? If not, please describe below why the date is pending.<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-area pending_release_explanation-input-group\">\n\n          <th for=\"pdb-pending_release_explanation-2\">Pending release explanation<\/th>\n\n          <td>\n\n            <textarea name=\"pending_release_explanation\" rows=\"2\" cols=\"40\" id=\"pdb-pending_release_explanation-2\"><\/textarea>\n\n                        <span class=\"helptext\">Please briefly describe why the release date is subject to change.<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio has_the_individual_been_previously_incarcerated_for_a_sexual_con-input-group\">\n\n          <th for=\"pdb-has_the_individual_been_previously_incarcerated_for_a_sexual_con-2\">Has the individual been previously incarcerated for a sexual offense?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Has the individual been previously incarcerated for a sexual offense?<\/legend>\n<label class=\"required-field\" for=\"pdb-has_the_individual_been_previously_incarcerated_for_a_sexual_con-yes-2\">\n<input name=\"has_the_individual_been_previously_incarcerated_for_a_sexual_con\" id=\"pdb-has_the_individual_been_previously_incarcerated_for_a_sexual_con-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-has_the_individual_been_previously_incarcerated_for_a_sexual_con-no-2\">\n<input name=\"has_the_individual_been_previously_incarcerated_for_a_sexual_con\" id=\"pdb-has_the_individual_been_previously_incarcerated_for_a_sexual_con-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio is_the_individual_currently_incarcerated_for_a_sexual_offense-input-group\">\n\n          <th for=\"pdb-is_the_individual_currently_incarcerated_for_a_sexual_offense-2\">Is the individual currently incarcerated for a sexual offense?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Is the individual currently incarcerated for a sexual offense?<\/legend>\n<label class=\"required-field\" for=\"pdb-is_the_individual_currently_incarcerated_for_a_sexual_offense-yes-2\">\n<input name=\"is_the_individual_currently_incarcerated_for_a_sexual_offense\" id=\"pdb-is_the_individual_currently_incarcerated_for_a_sexual_offense-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-is_the_individual_currently_incarcerated_for_a_sexual_offense-no-2\">\n<input name=\"is_the_individual_currently_incarcerated_for_a_sexual_offense\" id=\"pdb-is_the_individual_currently_incarcerated_for_a_sexual_offense-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        <span class=\"helptext\">Answer \"No\" if the individual is currently incarcerated for a non-sexual offense even if there is a past sexual offense on their record.<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"dropdown released_from_2-input-group\">\n\n          <th for=\"pdb-released_from_2-2\">Releasing Facility<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <select name=\"released_from_2\" id=\"pdb-released_from_2-2\" class=\"required-field\">\n<option value=\"\" selected=\"selected\">&nbsp;<\/option>\n<option value=\"Barstable County Correctional Facilty\">Barstable County Correctional Facilty<\/option>\n<option value=\"Berkshire County Jail and HOC\">Berkshire County Jail and HOC<\/option>\n<option value=\"Boston Pre-Release Center\">Boston Pre-Release Center<\/option>\n<option value=\"Bridgewater State Hospital\">Bridgewater State Hospital<\/option>\n<option value=\"Bristol County HOC and Jail\">Bristol County HOC and Jail<\/option>\n<option value=\"Dukes County Jail and HOC\">Dukes County Jail and HOC<\/option>\n<option value=\"Essex County Correctional Facility\">Essex County Correctional Facility<\/option>\n<option value=\"Franklin County Jail and HOC\">Franklin County Jail and HOC<\/option>\n<option value=\"Hampden County Jail and HOC\">Hampden County Jail and HOC<\/option>\n<option value=\"Hampshire County Jail and HOC\">Hampshire County Jail and HOC<\/option>\n<option value=\"Lemuel Shattuck Hospital Correctional Unit\">Lemuel Shattuck Hospital Correctional Unit<\/option>\n<option value=\"MASAC at Plymouth\">MASAC at Plymouth<\/option>\n<option value=\"Massachusetts Treatment Center\">Massachusetts Treatment Center<\/option>\n<option value=\"MCI-Cedar Junction\">MCI-Cedar Junction<\/option>\n<option value=\"MCI-Concord\">MCI-Concord<\/option>\n<option value=\"MCI-Framingham\">MCI-Framingham<\/option>\n<option value=\"MCI-Norfolk\">MCI-Norfolk<\/option>\n<option value=\"MCI-Shirley\">MCI-Shirley<\/option>\n<option value=\"Middlesex Jail and HOC\">Middlesex Jail and HOC<\/option>\n<option value=\"Nantucket County Jail\">Nantucket County Jail<\/option>\n<option value=\"Nashua Street Jail\">Nashua Street Jail<\/option>\n<option value=\"Norfolk County Correctional Center\">Norfolk County Correctional Center<\/option>\n<option value=\"North Central Correctional Institution\">North Central Correctional Institution<\/option>\n<option value=\"Northeastern Correctional Center\">Northeastern Correctional Center<\/option>\n<option value=\"Old Colony Correctional Center\">Old Colony Correctional Center<\/option>\n<option value=\"Plymouth County Correctional Facilty\">Plymouth County Correctional Facilty<\/option>\n<option value=\"Pondville Correctional Center\">Pondville Correctional Center<\/option>\n<option value=\"South Bay HOC\">South Bay HOC<\/option>\n<option value=\"Souza-Baranowski Correctional Center\">Souza-Baranowski Correctional Center<\/option>\n<option value=\"Worcester County Jail and HOC\">Worcester County Jail and HOC<\/option>\n<option value=\"Other\">Other<\/option>\n<\/select>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio state_or_civil-input-group\">\n\n          <th for=\"pdb-state_or_civil-2\">MTC Release Type<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">MTC Release Type<\/legend>\n<label class=\"required-field\" for=\"pdb-state_or_civil-state-2\">\n<input name=\"state_or_civil\" id=\"pdb-state_or_civil-state-2\" class=\"required-field\" type=\"radio\" value=\"State\" \/>\nState<\/label>\n<label class=\"required-field\" for=\"pdb-state_or_civil-civil-2\">\n<input name=\"state_or_civil\" id=\"pdb-state_or_civil-civil-2\" class=\"required-field\" type=\"radio\" value=\"Civil\" \/>\nCivil<\/label>\n<label class=\"required-field\" for=\"pdb-state_or_civil-na-2\">\n<input name=\"state_or_civil\" id=\"pdb-state_or_civil-na-2\" class=\"required-field\" type=\"radio\" value=\"n\/a\" \/>\nn\/a<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line who_will_transport_the_individual_from_the_releasing_facility-input-group\">\n\n          <th for=\"pdb-who_will_transport_the_individual_from_the_releasing_facility-2\">Who will transport the individual from the releasing facility?<\/th>\n\n          <td>\n\n            <input name=\"who_will_transport_the_individual_from_the_releasing_facility\" id=\"pdb-who_will_transport_the_individual_from_the_releasing_facility-2\" class=\" regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio supervision-input-group\">\n\n          <th for=\"pdb-supervision-2\">Is the individual under supervision?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Is the individual under supervision?<\/legend>\n<label class=\"required-field\" for=\"pdb-supervision-probation-2\">\n<input name=\"supervision\" id=\"pdb-supervision-probation-2\" class=\"required-field\" type=\"radio\" value=\"Probation\" \/>\nProbation<\/label>\n<label class=\"required-field\" for=\"pdb-supervision-parole-2\">\n<input name=\"supervision\" id=\"pdb-supervision-parole-2\" class=\"required-field\" type=\"radio\" value=\"Parole\" \/>\nParole<\/label>\n<label class=\"required-field\" for=\"pdb-supervision-none-2\">\n<input name=\"supervision\" id=\"pdb-supervision-none-2\" class=\"required-field\" type=\"radio\" value=\"None\" \/>\nNone<\/label>\n<label class=\"required-field\" for=\"pdb-supervision-unknown-2\">\n<input name=\"supervision\" id=\"pdb-supervision-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"dropdown court-input-group\">\n\n          <th for=\"pdb-court-2\">Court of Jurisdiction<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <select name=\"court\" id=\"pdb-court-2\" class=\"required-field\">\n<option value=\"\" selected=\"selected\">&nbsp;<\/option>\n<option value=\"Barnstable\">Barnstable<\/option>\n<option value=\"Berkshire\">Berkshire<\/option>\n<option value=\"Bristol\">Bristol<\/option>\n<option value=\"Dukes\">Dukes<\/option>\n<option value=\"Essex\">Essex<\/option>\n<option value=\"FEDERAL\">FEDERAL<\/option>\n<option value=\"Franklin\">Franklin<\/option>\n<option value=\"Hampden\">Hampden<\/option>\n<option value=\"Hampshire\">Hampshire<\/option>\n<option value=\"Middlesex (Lowell)\">Middlesex (Lowell)<\/option>\n<option value=\"Middlesex (Woburn)\">Middlesex (Woburn)<\/option>\n<option value=\"Nantucket\">Nantucket<\/option>\n<option value=\"Norfolk\">Norfolk<\/option>\n<option value=\"Plymouth\">Plymouth<\/option>\n<option value=\"Suffolk\">Suffolk<\/option>\n<option value=\"Worcester\">Worcester<\/option>\n<option value=\"N\/A\">N\/A<\/option>\n<\/select>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio gps-input-group\">\n\n          <th for=\"pdb-gps-2\">Does the individual have a GPS requirement?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Does the individual have a GPS requirement?<\/legend>\n<label class=\"required-field\" for=\"pdb-gps-yes-2\">\n<input name=\"gps\" id=\"pdb-gps-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-gps-no-2\">\n<input name=\"gps\" id=\"pdb-gps-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<label class=\"required-field\" for=\"pdb-gps-unknown-2\">\n<input name=\"gps\" id=\"pdb-gps-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio sor_level-input-group\">\n\n          <th for=\"pdb-sor_level-2\">Sex Offender Registration Board (SORB) designation<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Sex Offender Registration Board (SORB) designation<\/legend>\n<label class=\"required-field\" for=\"pdb-sor_level-0-2\">\n<input name=\"sor_level\" id=\"pdb-sor_level-0-2\" class=\"required-field\" type=\"radio\" value=\"0\" \/>\n0<\/label>\n<label class=\"required-field\" for=\"pdb-sor_level-1-2\">\n<input name=\"sor_level\" id=\"pdb-sor_level-1-2\" class=\"required-field\" type=\"radio\" value=\"1\" \/>\n1<\/label>\n<label class=\"required-field\" for=\"pdb-sor_level-2\">\n<input name=\"sor_level\" id=\"pdb-sor_level-2\" class=\"required-field\" type=\"radio\" value=\"2\" \/>\n2<\/label>\n<label class=\"required-field\" for=\"pdb-sor_level-3-2\">\n<input name=\"sor_level\" id=\"pdb-sor_level-3-2\" class=\"required-field\" type=\"radio\" value=\"3\" \/>\n3<\/label>\n<label class=\"required-field\" for=\"pdb-sor_level-unknown-2\">\n<input name=\"sor_level\" id=\"pdb-sor_level-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<label class=\"required-field\" for=\"pdb-sor_level-na-2\">\n<input name=\"sor_level\" id=\"pdb-sor_level-na-2\" class=\"required-field\" type=\"radio\" value=\"n\/a\" \/>\nn\/a<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-area mobility-input-group\">\n\n          <th for=\"pdb-mobility-2\">Describe any mobility issues.<\/th>\n\n          <td>\n\n            <textarea name=\"mobility\" rows=\"2\" cols=\"40\" id=\"pdb-mobility-2\"><\/textarea>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio has_the_individual_served_in_the_military_at_any_time-input-group\">\n\n          <th for=\"pdb-has_the_individual_served_in_the_military_at_any_time-2\">Has the individual served in the military at any time?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Has the individual served in the military at any time?<\/legend>\n<label class=\"required-field\" for=\"pdb-has_the_individual_served_in_the_military_at_any_time-yes-2\">\n<input name=\"has_the_individual_served_in_the_military_at_any_time\" id=\"pdb-has_the_individual_served_in_the_military_at_any_time-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-has_the_individual_served_in_the_military_at_any_time-no-2\">\n<input name=\"has_the_individual_served_in_the_military_at_any_time\" id=\"pdb-has_the_individual_served_in_the_military_at_any_time-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio health_care-input-group\">\n\n          <th for=\"pdb-health_care-2\">Has MassHealth coverage been activated?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Has MassHealth coverage been activated?<\/legend>\n<label class=\"required-field\" for=\"pdb-health_care-yes-2\">\n<input name=\"health_care\" id=\"pdb-health_care-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-health_care-no-2\">\n<input name=\"health_care\" id=\"pdb-health_care-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<label class=\"required-field\" for=\"pdb-health_care-unknown-2\">\n<input name=\"health_care\" id=\"pdb-health_care-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"dropdown bhji_activation-input-group\">\n\n          <th for=\"pdb-bhji_activation-2\">With which BHJI organization have services been initiated.<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <select name=\"bhji_activation\" id=\"pdb-bhji_activation-2\" class=\"required-field\">\n<option value=\"\" selected=\"selected\">&nbsp;<\/option>\n<option value=\"Advocates\">Advocates<\/option>\n<option value=\"Baystate Community Services\">Baystate Community Services<\/option>\n<option value=\"Behavioral Health Network\">Behavioral Health Network<\/option>\n<option value=\"Center for Human Development\">Center for Human Development<\/option>\n<option value=\"Community Counseling of Bristol County\">Community Counseling of Bristol County<\/option>\n<option value=\"Gavin Foundation\">Gavin Foundation<\/option>\n<option value=\"Gosnold\">Gosnold<\/option>\n<option value=\"Open Sky Community Services\">Open Sky Community Services<\/option>\n<option value=\"Riverside Community Care\">Riverside Community Care<\/option>\n<option value=\"None\">None<\/option>\n<\/select>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio birth_certificate-input-group\">\n\n          <th for=\"pdb-birth_certificate-2\">Does the individual have their birth certificate<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Does the individual have their birth certificate<\/legend>\n<label class=\"required-field\" for=\"pdb-birth_certificate-yes-2\">\n<input name=\"birth_certificate\" id=\"pdb-birth_certificate-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-birth_certificate-no-2\">\n<input name=\"birth_certificate\" id=\"pdb-birth_certificate-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<label class=\"required-field\" for=\"pdb-birth_certificate-unknown-2\">\n<input name=\"birth_certificate\" id=\"pdb-birth_certificate-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio social_security-input-group\">\n\n          <th for=\"pdb-social_security-2\">Does the individual have a social security card?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Does the individual have a social security card?<\/legend>\n<label class=\"required-field\" for=\"pdb-social_security-yes-2\">\n<input name=\"social_security\" id=\"pdb-social_security-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-social_security-no-2\">\n<input name=\"social_security\" id=\"pdb-social_security-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<label class=\"required-field\" for=\"pdb-social_security-unknown-2\">\n<input name=\"social_security\" id=\"pdb-social_security-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio mass_id-input-group\">\n\n          <th for=\"pdb-mass_id-2\">Does the individual have a valid Massachusetts ID?<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Does the individual have a valid Massachusetts ID?<\/legend>\n<label class=\"required-field\" for=\"pdb-mass_id-yes-2\">\n<input name=\"mass_id\" id=\"pdb-mass_id-yes-2\" class=\"required-field\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label class=\"required-field\" for=\"pdb-mass_id-no-2\">\n<input name=\"mass_id\" id=\"pdb-mass_id-no-2\" class=\"required-field\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<label class=\"required-field\" for=\"pdb-mass_id-unknown-2\">\n<input name=\"mass_id\" id=\"pdb-mass_id-unknown-2\" class=\"required-field\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"radio property-input-group\">\n\n          <th for=\"pdb-property-2\">Does the individual have property to be acquired upon release?<\/th>\n\n          <td>\n\n            <div class=\"radio-group\">\n<fieldset class=\"no-border\">\n<legend class=\"screen-reader-text\">Does the individual have property to be acquired upon release?<\/legend>\n<label for=\"pdb-property-yes-2\">\n<input name=\"property\" id=\"pdb-property-yes-2\" type=\"radio\" value=\"Yes\" \/>\nYes<\/label>\n<label for=\"pdb-property-no-2\">\n<input name=\"property\" id=\"pdb-property-no-2\" type=\"radio\" value=\"No\" \/>\nNo<\/label>\n<label for=\"pdb-property-unknown-2\">\n<input name=\"property\" id=\"pdb-property-unknown-2\" type=\"radio\" value=\"Unknown\" \/>\nUnknown<\/label>\n<\/fieldset><!-- .no-border --><\/div><!-- .radio-group -->\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line massachusetts_contact-input-group\">\n\n          <th for=\"pdb-massachusetts_contact-2\">Massachusetts housing contact name<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"massachusetts_contact\" id=\"pdb-massachusetts_contact-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-area massachusetts_address-input-group\">\n\n          <th for=\"pdb-massachusetts_address-2\">Massachusetts housing address<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <textarea name=\"massachusetts_address\" rows=\"2\" cols=\"40\" id=\"pdb-massachusetts_address-2\" class=\"required-field\"><\/textarea>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line massachusetts_phone-input-group\">\n\n          <th for=\"pdb-massachusetts_phone-2\">Massachusetts housing contact phone<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"massachusetts_phone\" id=\"pdb-massachusetts_phone-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-area travel-input-group\">\n\n          <th for=\"pdb-travel-2\">If leaving Massachusetts, what travel arrangements have been secured?<\/th>\n\n          <td>\n\n            <textarea name=\"travel\" rows=\"2\" cols=\"40\" id=\"pdb-travel-2\"><\/textarea>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line emergency_contact-input-group\">\n\n          <th for=\"pdb-emergency_contact-2\">Emergency contact (name and phone)<\/th>\n\n          <td>\n\n            <input name=\"emergency_contact\" id=\"pdb-emergency_contact-2\" class=\" regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line name_of_submitter-input-group\">\n\n          <th for=\"pdb-name_of_submitter-2\">Name of party completing questionnaire.<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"name_of_submitter\" id=\"pdb-name_of_submitter-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line email_of_submitter-input-group\">\n\n          <th for=\"pdb-email_of_submitter-2\">Email of party completing questionnaire<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"email_of_submitter\" id=\"pdb-email_of_submitter-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line name_of_organization_submitter-input-group\">\n\n          <th for=\"pdb-name_of_organization_submitter-2\">Name of organization completing questionnaire.<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"name_of_organization_submitter\" id=\"pdb-name_of_organization_submitter-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-area special_notes-input-group\">\n\n          <th for=\"pdb-special_notes-2\">Special Notes:<\/th>\n\n          <td>\n\n            <textarea name=\"special_notes\" rows=\"2\" cols=\"40\" id=\"pdb-special_notes-2\"><\/textarea>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n                \n        <\/tbody>\n\n            \n        <tbody class=\"field-group field-group-submit\">\n      \n        <tr>\n          <td class=\"submit-buttons\">\n            \n           <input name=\"submit_button\" class=\"button-primary pdb-submit\" type=\"submit\" value=\"SUBMIT Questionnaire [A confirmation email from BRN will indicate receipt of this form.]]\" \/>\n            \n          <\/td>\n          <td class=\"submit-buttons\">\n            \n           <span class=\"pdb-retrieve-link\"><a href=\"\/index.php\/wp-json\/wp\/v2\/pages\/657?m=r\">Forget your private link? Click here to have it emailed to you.<\/a><\/span>           \n          <\/td>\n        <\/tr>\n        \n      <\/tbody>\n      \n    <\/table>\n    \n  <\/form>  \n<\/div>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; &nbsp;<\/p>\n","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-657","page","type-page","status-publish"],"_links":{"self":[{"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/pages\/657","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/comments?post=657"}],"version-history":[{"count":5,"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/pages\/657\/revisions"}],"predecessor-version":[{"id":1149,"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/pages\/657\/revisions\/1149"}],"wp:attachment":[{"href":"https:\/\/baystatereentrynetwork.org\/index.php\/wp-json\/wp\/v2\/media?parent=657"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}