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(click the print button in the upper right corner) PERSONAL DATA: Name: _______________________ DOC Number: _________________ Institution: ____________________ Building, Block, or Ward: ________ Street Address: ________________________________________________ Sex: Male Female Birthdate: _________ City: ________________________________________________ State: ____________ Zip ____________ Current Date: ___________ Marital Status: Married Single Divorced Date of Incarceration, Above Institution: __________ Expected Release or Transfer Date: ________ TELL US ABOUT YOU: What is your educational background? (Check All Completed) GED High School College/University Grade School Technical/Trade School What kind of sporting activities do you enjoy, or have participated in during your life? (Check all that apply) Baseball Basketball Football Golf Tennis Soccer Wrestling Volleyball Track & Field Snow Skiing Water Skiing Raquetball Gymnastics Swimming Other _______________ What other hobbies and interests do you have? ______________________________________________________________________________________ ______________________________________________________________________________________ What have been your job related activities? ______________________________________________________________________________________ ______________________________________________________________________________________ What are your career interests or goals once released? ______________________________________________________________________________________ ______________________________________________________________________________________ What is your most favorite thing to be involved in, and why? ______________________________________________________________________________________ ______________________________________________________________________________________ TELL US ABOUT YOUR FRIENDS AND FAMILY: Growing up, which circumstance best describes your parental situation? (Check One) Both Parents Married to Each Other Divorced – Single Parent Divorced – Remarried Single Parent – Never Married Raised By Other Family Were you raised by: (Check One) Father? Mother? Both? Growing up, what was you situation as far as brothers or sisters? (Give numbers that apply) ____ Brothers ____ Sisters ____ Half or Step Brothers ____ Half or Step Sisters ____ Foster Brothers ____ Foster Sisters Do you have children? (Give numbers that apply) ____ Sons __________ Ages ____ Daughters __________ Ages What current family members do you have contact with on a regular basis? (List) ______________________________________________________________________________________ ______________________________________________________________________________________ Of the family members that have contact, how is the contact made? (Check All That Apply) Mail Visits Phone Describe the closeness of you family relationships overall? ______________________________________________________________________________________ ______________________________________________________________________________________ Are you in contact with friends? If so, how is the contact made? (Check All That Apply) Mail Visits Phone TELL US ABOUT YOUR SPIRITUAL BELIEFS AND TRADITIONS: Growing up, was there any spiritual teaching or spiritual climate in the home? Yes No If there was a spiritual climate in the home, was it: (Check all that apply) Christian Jewish Islam Mormon Hindu Buddhism Other (Describe) ___________________ Of the world religions, I am most familiar with ____________? Which of the following best represents your view of God? (Check One) God exists and we can know him and who he is. God exists but we cannot know him, he is impersonal. God exists and may be known by other people but not by me personally. God exists but can only be known by a select group of people. God does not exist. What are your current beliefs about heaven/hell? There is no heaven or hell. There is a hell, but no heaven. There is a heaven, but no hell. There is a heaven and a hell. If you died today, would God allow you into Heaven? Why or why not? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ What is your past and current knowledge, relationship, or belief about Jesus Christ? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Thank you for your time in filling out this questionnaire. We hope and pray that this will be the first step in developing a close and personal relationship with someone who will assist you in finding your spiritual place and purpose in this life. Please return this questionnaire to the address below. Grace In Jail, c/o Grace Community Church, 20076 C.R. 36, Goshen, IN 46526 |