Reentry Assistance Intake

Apply for reentry assistance

This confidential intake form is open to both women and men returning from incarceration. Share your details below and our team will follow up to guide you through the next steps. Fields marked with an asterisk are required.

Contact information

Full name *

Phone number *

Email address *

I identify as *

How you found us

Referral source *

Referral details

Eligibility details

These help us understand your situation. Share what you can — every field here is optional.

Current incarceration status

Release / expected release date

Supervision status

Current housing situation

Employment status

Source of income

Recovery / sobriety status

What support are you looking for?

Anything else you'd like us to know?

I consent to Success & Serenity contacting me about my application and storing the information I've provided for intake purposes. *