Intake Form

All fields marked with * are required.

Client Information

First Name of Client *

Middle Name

Last Name of Client *

Suffix

Client Date of Birth *

Clilent Race *

Client Gender *

Client LGBTQIA?

Is there anything we should know about this person or their circumstances?

Has this person consented to being bailed out? *

Does this person need a ride once they are bailed out? If so, where to? *

Are there any holds on this person that would restrict them from being released immediately if there bail is posted? This includes currently serving a sentence, charges in other counties or states, active warrants, federal charges, or pending charges. *

Community Contact Information

Is there somebody connected to the person who can give them a ride? If so, what is their name? *

What is their phone number?

What is their email address?

What is your name? *

What is your relationship to the client? *

Please provide your phone number: *

Bail and Case Information

Total Bail Amount for this Client *

What jail is the person being held at? (We are currently only bailing folks out of the Greenfield and Northampton, MA jails AKA Hampshire and Franklin Counties) *

Is there anybody who can contribute to the bail payment? If yes, what is their contact information (phone and/or e-mail)? *

Docket Number

Can the client communicate in English?

Does the client have somewhere to stay upon release? *

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