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Client Survey

We're glad you came in today!

  • Can we offer you a water? Snack?

  • We are re-entry specialists, please take my card and don't hesitate to call. We are open five days a week from 8:30 to 2 p.m., except for national holidays. Our website OHPM.org has a list of strategic partners that offer services you'll find exceptionally helpful.

  • Our restroom is over there. You're welcome to use it before we get started if you like. Ready to get started?

1. Have you been to Operation Hope Prison Ministry before?
Yes
No (Skip to 2)

How can we help?

Incarceration History

3. Have you ever been incarcerated?
Yes
No (Skip to 4.)
Discharge Date
Month
Day
Year
Are you on Probation or Parole?
Yes
No
Are you required to register with Offender Registration?
Yes
No

Client Contact

Birthday
Month
Day
Year
Gender
Male
Female

Housing

Employment

Are you currently employed?
Yes
No (Need help finding a job?) Skip to 5

Skills & Education

Service to Country

6. Are you a veteran?
Yes
No (Skip to 7)
Do you have a DD214?
Yes
No

Ethnicity

7. Ethinicity
8. Are you an enrolled Tribal member?
Yes
No (Go to 9)
Do you have a CDIB- Certificate Of Indian Blood card?
Yes
No
I might qualify

Your Clothing Sizes

T-Shirt Size:
Underware size:
Jean Size?
Womens Sports Bras

Existing Benefits Assessment

10. Do you have a SNAP or food card?
Yes
No
I might qualify
11. Do you have a disability and disability benefits?
Yes
No
I might qualify
12. Do you get Social Security Insurance Benefits?
Yes
No
13. Would you like information on recovery meetings (CR, AA, NA)?
Yes
No

About your Family

Faith Journey

11. Do you have a Bible?
Yes
No
I'd like a Bible

Give the Client your Ministry Card and introduce our website: OHPM.org

  • As your re-entry specialist, I am ready to help you navigate and connect with essential resources. Our website, OHPM.org has a comprehensive list of our services, strategic partners and links to their ministries and government agencies. Please explore them.

  • We love it when you come see us in-person, but your life is going to get busy with work and responsibilities, so we've made it so you can check-in online and report on your successes, completed assignments and appointments. And we'll phone you or email you next steps and more referrals to help you get re-established and independent.

  • When you UPDATE YOUR RE-ENTRY PLAN" online, Operation Hope will respond and offer advanced services and connections to you.

  • Operation Hope offers the following services during first visits:

Services Offered/Provided today

My client will leave/left today with:

Final Questions:

Did your interviewer give you their ministry card and show you how to UPDATE YOUR RE-ENTRY PLAN on our website, OHPM.org?
Yes, I was given a ministry card
No, I had to ask for a ministry card.

WE KINDLY REQUEST PERMISSION TO USE YOUR PHOTOGRAPH, NAME AND/OR TESTIMONIAL BY OPERATION HOPE PRISON MINISTRIES, its representatives, strategic partners, volunteers, and employees. I grant the right to use my image and authorize Operation Hope Prison Ministry to use any photographs, video, audio, written quote or images of me for any lawful purposes to include, such purchases as publicity, illustration, social media, advertising and web content.


My electrionic signature is valid as a blue ink signature.

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Date and time
Month
Day
Year
Time
HoursMinutes

_____________________________________

For Official Use ONLY

Interviewer Notes Below:

Recommendations for future services:

These advanced services may also be offered at a future visit. Kindly review these with your client.
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