Assessment | Native Wings

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First name*

Last name*

Tribe*

ID TYPE TRIBAL/STATE/ODOC:*

ID#*

Email*

Phone*

Birthday*

Sex

Male

Female

Country/Region*

Address*

City*

Zip / Postal code*

INSTITUTIONAL INFORMATION

FACILITY/CORRECTIONAL CENTER

DOC#

CONVICTION

COUNTY OF CONVICTION

SENTENCE

RELEASE DATE

TYPE OF RELEASE

NEXT PAROLE HEARING DATE

CASE MANAGER

LENGTH OF INCARCERATION

JUVENILE RECORD

Yes

No

Choose one

PAROLE

PROBATION

COMMUTATION

PROBATION/PAROLE OFFICER

OFFICER #

ADDRESS

PROBATION FEES AMOUNT

PAID UP TO DATE

Yes

No

HOW MANY TIMES DO YOU HAVE TO CONTACT YOUR PROBATION OFFICER?

PLEASE TELL US ABOUT YOUR CONVICTION IN DETAIL, AND WHAT LED TO YOUR RECENT INCARCERATION

NEEDS

SHIRT SIZE

PANT SIZE

SHOE SIZE

DO YOU NEED ADDITIONAL TOOLS/SPECIALTY ITEMS TO WORK IN YOUR TRADE?

Yes

No

DO YOU HAVE DRIVERS LICENSE?

Yes

No

IF NO, WHAT HAPPENED?

WHAT IS OR WILL BE YOUR MODE OF TRANSPORTATION?

IS YOUR TRANSPORTATION RELIABLE?

Yes

No

HAVE YOU EVER USED PUBLIC TRANSPORTATION?

ARE YOU WILLING TO ACCEPT MENTORING, COUNSELING, AND LEADERSHIP TO GET YOUR NEEDS MET?

Yes

No

WHAT TYPE OF DOCUMENTATION DO YOU NEED FOR IDENTIFICATION PURPOSES?

SOCIAL SECURITY CARD

DRIVERS LICENSE

STATE ID

CDIB

BIRTH CERTIFICATE

TRIBAL CARD

ARE THERE ANY OTHER NEEDS THAT HAVE NOT BEEN LISTED?

PLEASE SELECT ALL THE SERVICES YOU HAVE APPLIED FOR

ADULT PROTECTIVE SERVICES

TANF

EMPLOYMENT AND TRAINING

CHILD SUPPORT

SOCIAL SERVICES

COMMODITIES

CHILD CARE

HIGHER EDUCATION

LEGAL SERVICES

TERO

HOUSING

CHILDREN AND FAMILY

FOOD STAMPS

MEDICAID

MEDICARE

HAVE YOU RECEIVED ANY OTHER REINTEGRATION SERVICES? IF YES PLEASE EXPLAIN

EMPLOYMENT AND EDUCATION

WHAT IS YOUR PREVIOUS WORK EXPERIENCE? HOW LONG AND DATES

DO YOU HAVE ANY REFERENCES

DO YOU HAVE ANY CERTIFICATIONS, DIPLOMAS OR DEGREES?

Yes

No

CAN YOU PROVIDE COPIES IF YES?

Yes

No

ARE YOU INTERESTED IN ANY VOC TRAINING?

Yes

No

IF YES, WHAT ARE YOUR INTERESTS?

HAVE YOU EVER ATTENDED COLLEGE OR VO-TECH?

Yes

No

IF YES, WHAT ARE THE DATES AND WAS YOUR MAJOR?

PLEASE SELECT IF YOU HAVE EVER APPLIED/USED ANY ASSISTANCE WHILE EDUCATION TRAINING

PELL GRANT

TRIBAL TUITION ASSISTANCE

SCHOLARSHIPS

STUDENT LOANS

VOCATIONAL REHABILITATION

ANY OTHER ASSISTANCE?

IF YOU RECEIVED ANY STUDENT LOANS, WHAT IS THE STATUS?

WHAT PROGRAMS HAVE YOU COMPLETED WHILE INCARCERATED?

MEDICAL AND MENTAL HEALTH

DO YOU HAVE ANY TYPES OF DISABILITIES THAT WOULD IMPAIR EMPLOYMENT: IE: DIABETES, HYPERTENSION, HEART ATTACK, STROKE, DOCUMENTED SUBSTANCE ABUSE, DOCUMENTED MENTAL HEALTH, DECREASED MOBILITY, OR PHYSICAL LIMITATIONS? PLEASE EXPLAIN

WHEN WAS YOUR LAST PHYSICAL EXAMINATION?

RESULTS OF EXAMINATION

WHAT CLINIC/HOSPITAL OR PRIMARY CARE OFFICE DO YOU USE OR WOULD LIKE TO

DO YOU CURRENTLY REQUIRE MEDICAL ASSISTANCE OR MEDICATION? IF YES WHAT?

DO YOU USE OR HAVE PREVIOUSLY USED ALCOHOL, DRUGS INCLUDING MARIJUANA, OR TOBACCO?

DO YOU HAVE OR HAVE YOU PREVIOUSLY HAD ANY ADDICTIONS TO ALCOHOL, DRUGS OR TOBACCO? IF YES WHAT?

WHAT IS YOUR DRINK OR DRUG OF CHOICE?

DO YOU FEEL YOU HAVE AN ACTIVE ADDICTION? IF YES WHAT?

IF SOBER HOW LONG HAVE YOU BEEN CLEAN?

WERE YOU UNDER THE INFLUENCE OF ANY SUBSTANCES DURING THE TIME YOU WERE ARRESTED FOR YOUR ALLEGED CRIME?

ARE YOU PHYSICALLY ABLE TO PARTICIPATE IN COMMUNITY SERVICE AND/OR VOLUNTEERING?

Yes

No

ARE YOU WILLING TO BE SUBJECT TO RANDOM URINALYSIS TESTING DURING YOUR TIME IN OUR PROGRAM? * SAYING NO MAY SUBJECT YOU TO DENIAL OF ENTRY TO THE “OFF THE REZ PROGRAM

Yes

No

ANY OTHER MEDICAL INFORMATION YOU WOULD LIKE US TO KNOW?

ADDITIONAL INFORMATION

ARE YOU A VETERAN?

Yes

No

IF YES, WHAT BRANCH AND TYPE OF DISCHARGE?

DO YOU HAVE A SPECIFIC RELIGIOUS AFFILIATION?

HOW DID YOU HEAR ABOUT NATIVE WINGS?

Contact Us

1207 Sovereign Row, Suite B

Oklahoma City, 73108

Main Phone: 405-724-7977

info@nativewings.org

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