Intake Form

All fields marked with * are required.

Information about the person who needs bond assistance:

First Name *

Middle Name

Last Name *

Suffix

Birthdate

To the best of your knowledge, what date was this person arrested? *

Race *

Gender *

Pronouns

Address *

Address Line 2

City *

State *

Zip *

Phone Number

To the best of your knowledge is the person a member of any of the following risk groups: LGBTQIA++, Adolescent, Over 60, Pregnant, Mentally -Ill, Chronically Ill, Phsyically disabled, Other? This information will not be disclosed to anyone outside of our organization without the express permission of the person to be bailed and is only utilized to assist in our decision-making process.

Special Concerns

Is this person currently experiencing homelessness? (This question allows us to direct the person to be bailed towards resources which might be helpful to them.)

Will this person require transportation assistance upon leaving the Forsyth County Law Enforcement Detention Center at 201 N Church St, Winston-Salem, NC 27101? *

If they require assistance, please include more details here:

Transportation Assistance Details

Attorney Contact Information

If this person has retained or been assigned an attorney, please list the name and contact information of the attorney.

Attorney Name

Attorney Phone Number

Attorney Email Address

Community Contact/Referrer Info

Please provide contact information for yourself or someone else who can be contacted regarding this case, if needed

Name

Relationship To The Client

Phone Number

Email Address

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