Synergy Transitional Housing – Reentry Housing Application
SYNERGY TRANSITIONAL HOUSING INC.
Reentry Housing Application
Application for individuals transitioning from incarceration
SECTION 1: PERSONAL & CONTACT INFORMATION
First Name
*
Last Name
*
Date of Birth
*
Last 4 of SSN
Phone Number
*
Email Address
SECTION 2: INCARCERATION & RELEASE
Prison/DOC Number
Facility Name
Actual / Expected Release Date
*
Sentence (length / time served)
Current legal status (check one)
*
On parole
On probation
No supervision
Primary offense(s)
SECTION 3: HOUSING NEEDS
Current housing situation
*
No housing arranged (homeless if released today)
Temporary place (friend/family, hotel, shelter)
Stable housing already secured
If you cannot return to your prior residence, briefly explain why
What type of housing support are you requesting from Synergy?
SECTION 4: EMPLOYMENT & INCOME
Current employment / income status
-- Select --
Unemployed
Actively seeking work
Employed (on work release or pre‑hire)
Disability / fixed income
Other
Work history / skills (brief)
SECTION 5: SUPPORTS & SERVICES
Do you have any mental health or substance use treatment needs you want help with?
Yes
No
Unsure / would like to discuss
List any important supports (family, friends, community programs, probation/parole officer)
SECTION 6: STATEMENT & SIGNATURE
Briefly explain why you are requesting reentry housing and your goals after release
Applicant Name (print)
*
Date
*
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