Fillable MAYORS INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & (City of Bridgeport)

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MAYORS INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & (City of Bridgeport)

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MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 1 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

PLEASE PRINT:

 Initial intake | Date Completed: _______  Reassessment/Intake I Date of Last Assessment: _____

Client Information

Name: _______________________________________Date of Birth: __________ Age: ___ Gender: Male / Female

Primary Address: _____________________________________________________________________________

Primary Phone: ___________________________ Secondary Phone: ___________________________

Best Time to Contact: ☐ AM ☐ PM Best Time to Contact: ☐ AM ☐ PM

Email: _____________________________ SSN:

Race: ☐ African American ☐ White ☐ American Indian ☐ Hispanic ☐ Asian ☐ Pacific Islander ☐ Alaska

Native

Ethnicity: ___________________________

Relationship Status:_________________________ Primary Language:___________________________

Veteran Status: Yes  No 

Registered Voter: Yes  No 

Are you a US Citizen? □ Yes □ No If no, country of origin:

Do you have a Visa or Green Card? □ Yes □ No

Do you have ID and Documentation? Yes  No 

Active Drivers License or State ID Yes  No  Birth Certificate Yes  No  Social Security Card

Have you ever been convicted? □ Yes □ No - If yes, Nature of your offense:

End of Sentence Date:__________________

What correctional facility were you recently released from? _______________________ Date of Release:______________

What halfway house or community facility are you in currently if any? ____________________________________

Number of days in jail/prison in past 6 months: _________

How did you hear about MIRA?

______________________________

______________________________________

___________

_________

____

________________________________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 2 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

Please complete this section if this is an agency referral. Agency Referred To ☐ _________________ From ☐ _________________

Date of Referral

Date of

Appointment or

release

Verified Appointment:

☐ Yes ☐ No

Agency Name:

Telephone (Main)

Address:

City:

State: CT

Zip: 06604

Contact Person

Contact email:

Referring Person:

Contact Phone:

Do you have children: Yes  No 

Members in household other than Client (if applicable)

Name

Age

Gender

Relationship

Name/address of school

or readiness program or

day care

Service Needs

Nearest relative or friend not living with Client and others to contact for emergencies or to reach Client

Name

Address

Phone

Relationship

Verified Appointment:

_________________________

____________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 3 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

Employment and Education

Are you currently Employed: Yes

Yes, but seeking opportunities ☐ No ☐ No, not able to work at this time ☐

Worked in the past 6 months: Yes  No

Percent of time Client has worked in the past 6 months (for example, 3 months = 50 %): __________________

Interested in a Full time  OR Part time position 

Note employer, type of job, length of employment and hours worked per week

________________________________________________________________________________________________

Highest Grade Completed: _________

Graduated from High School: ☐ Yes ☐ No Grade dropped out:

GED: ☐ Yes ☐ No

List any certifications or trainings:

________________________________________________________________________________________________

Currently enrolled in an education program: Yes  No  If yes, note program: _____________________________

What motivates you? Career, rebuilding your future, working toward personal or family goals.

________________________________________________________________________________________________

What type of work are you looking for?

________________________________________________________________________________________________

What are your goals for 6 months? One year? Two years?

________________________________________________________________________________________________

______________________________________________________________________________________________________________

What are your goals for six months? One year? Two years?

______________________________________________________________________________________________________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 4 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

___________________________________________________________________________________

_____________

________________________________________________________________________________________________

Employment and/or education goals:

________________________________________________________________________________________________

What motivates you? Career, rebuilding your future, working toward personal or family goals.

________________________________________________________________________________________________

I am interested in the following:

☐ Child Care

☐ Clothing

□ Disability

☐ Education/Certification

☐ Employment/ Job training

☐ Food

☐ Homeless

☐ Housing/Rent

☐ Medical treatment

☐ Mental health treatment

☐ No/Limited Work History

☐ Parole/Probation

☐ Pardon Process

☐ Parenting skills/Education

☐ Personal/family factors

☐ Phone

☐ Program Referral – Name

__________________________________

☐ Substance abuse treatment

☐ Support Services

☐ Transportation

☐ Utilities

□ I am not interested in receiving services at this time and I do not want a consultation appointment.

What type of work are you looking for?

Educational and/or career goals:

___________________________________________________________________________________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 5 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

Financial Resources, Obligations and Literacy

 None  Public Assistance  Retirement  Salary  Disability Other Unknown

Do you currently have a checking or savings account? Yes  No 

Can you balance a check book and manage your personal finances? Yes  No 

Do you know your current credit score or need your credit repaired? Yes  No 

Would financial literacy benefit you or your family? Yes  No 

Are you receiving assistance from any other Agencies/Support groups or person? ☐ Yes ☐ No

If yes, list name of Agency/Support group or person:

What type of benefits are you receiving?

Medical and Health

Provider

Name

Phone

Last

Appointment

Primary Care

Specialist /Mental Health

Medical insurance carrier and ID number: ______________________________________

CT DOC Mental Health Score___ CT DOC Substance Abuse Score

Currently using any illegal substances? Yes  No 

If yes, current harm reduction goals: _______________________________________________________________

If no, when was the last time you used any illegal substances? ______________________

Current health challenges, medical problems and known allergies:

________________________________________________________________________________________________

If yes, current harm reduction goals: __________________________________________________________________________

________________________________________________________________________________________________________

If no, when was the last time you used illegal substances? _________________________________________________________

Would you attend a FREE financial literacy course?

____

What is your total yearly income? _______________________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 6 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

___________________________________________________________________________________

_____________

________________________________________________________________________________________________

Medical treatment history including hospitalizations (indicate past 6 months or current): Yes  No 

ER visits in past 6 months: ___ _

Behavioral Health, Substance Use and Trauma

Provider

Name

Phone

Last

Appointment

Clinician

Case Manager

Other:

Currently using substances? Yes  No  If yes, current harm reduction goals:

Days in a residential program and/or inpatient in past 6 months: _______

DDAP Assessment

Community-based services connected to in past 6 months:

Current health challenges, medical problems, and known allergies:

_________________________________________________________________________________________________

Medical treatment history including hospitalizations (indicate past 6 months or current):

_________________________________________________________________________________________________

ER visits in past 6 months: _______

DDAP Assessment:

Community Based Services connected to in the past 6 months:

Mental Health Treatment Substance Abuse Treatment

Employment

Educational Services Volunteer Organization

Health/Medical Services

DDAP Assessment

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 7 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

 Mental Health treatment  Substance Abuse Treatment  Employment

Services

 Educational Services  Volunteer Organization  Health/Medical Services

Number of days in jail/prison in past 6 months: _________

Days in a residential program and/or inpatient in past 6 months: _______ ER visits in past 6 months: ________

Trauma history:

Introduction – we’re going to talk regarding situations that you may have seen or experienced at different points in your life.

You don’t have to answer any questions if you do not feel comfortable, and we can stop this part of the assessment at any

time you would like. We can also talk about concerns you may have in this area.

________________________________________________________________________________________________

Housing History and Information

Living Situation: ______________________________ Homeless in last 6 months?  Yes  No

Number of days in last 30 that Client has lived in a controlled environment: ______

Days in group home/ halfway housing in the past 30 days: ______ and in the past six months: _______

Number of self-help meetings attended in last 30 days: ____

Client Interacted with Family/Friends supportive of recovery in past 30 days:  Yes  No

If this is an initial intake/assessment, what is the amount of time homeless in past 3 year’s _____________

Legal Involvement

Provider

Name

Phone

Parole officer

Number of days in jail/prison past 6 months:

Number of days in a residential program/or inpatient past 6 months:

ER visits past 6 months:

__________________

_________________

______________

If this is the initial intake/assessment, what is the amount of time homeless past 3 years: __________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 8 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

Probation Officer

Attorney

DCF Worker

(EOS) End of Sentence date:

History of legal involvement: Include arrests, convictions, and incarcerations, pending court dates, involvement with child

welfare, attorney and current status:

________________________________________________________________________________________________

Services

Services individual would like to participate in/access:

________________________________________________________________________________________________

___________________________________________________________________________________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 9 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

___________________________________________________________________________________

_____________

________________________________________________________________________________________________

Additional Information

________________________________________________________________________________________________

_____________________________________________________________________________________________________

MAYOR’S INITIATIVE OF REENTRY AFFAIRS (M.I.R.A.) APPLICATION & ASSESSMENT FORM

M.I.R.A. 10 6/08/2020

Earl L. R. Bloodworth Director

Margaret E. Morton

Government Center

999 Broad Street

Bridgeport, CT 06604

203-330-4235 (Main Ofc. Phone)

MIRA.Service@BridgeportCT.Gov

___________________________________________________________________________________

_____________

________________________________________________________________________________________________

Additional Information Additional Information

Office Use Only:

MIRA Staff Name:

Service/Referral Provided:

Comments:

SUMMARAY NOTES

________________________________________________________________________________________________

_____________________________________________________________________________________________________

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Completed 22 January 2021

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