Entrepreneurship Application

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Justice involved background

How much time has passed since your last arrest and/or conviction?

Have you ever seen your criminal record?  *YesNo

If yes, do you have a copy of your criminal record?YesNo

Were you arrested and/or convicted in the state of RI? *YesNo

Are you currently being supervised on State or Federal Probation/Parole? *YesNo

Please enter the date of expiration of supervision: *

How often are you required to report your probation/parole agent? *

Name of your Probation/Parole agent (First & Last name):

Address where you report to your probation/parole agent: *

How long of a sentence did you service in jail or prison (Include multiple time served):

Have you obtained or requested/applied for an expungement for any cases for which you were arrested? *YesNo

If you served time in prison, did you work while incarcerated? *YesNo

If yes, please describe the jobs and/or work details that you were assigned if any: *

Have you completed any programs, mandates, or courses that can attest to your rehabilitation, lifestyle change, and prosocial living (including, but not limited to drug court, probation/parole, addiction treatment, anger management, parenting, or others)? *YesNo

If "yes", please describe:

What would you describe as any achievements or areas of accomplishments while incarcerated (if applicable)? *YesNo

What is your dream? *

Educational Background

What is the highest grade completed from k-12? *

Do you have a GED or high school diploma? *YesNo

If yes, date or year of completion/graduation:

If applicable what is the highest level of education beyond high school or GED?

Did you complete any vocational training programs? *YesNo

If yes, what kind of skill(s) did you acquire?

Values Survey

Please rank the following items 1-4 using the following scale: 1. Not important 2. Somewhat important 3. Very important 4. Extremely important

Money *

Love *

Family *

Health *

Marriage *

Freedom *

Job *

Life Insurance *

Safety *

Health Insurance *

Liveable Wage/Income *

Financial Security *

Voting *

Crime *

Personal Independence *

Religion *

Recovery *

Housing *

Education *

Justice *

Career Advancement *

Children *

What would you describe as the greatest accomplishment of your life?

Assessment

Each statement below describes how a person might feel when starting a program or approaching problems in their lives please indicate the extent to which you tend to agree or disagree with each statement. In each case make your choice in terms of how you feel right now not what you have felt in the past or how you would like to feel for all statements that refer to your "problem" answer in terms of problems related to your current situation.

I'm not the problem one. It doesn't make much sense for me to consider changing. *

I am finally doing some work on my problem. *

I've been thinking that I might want to change something about myself. *

At times my problem is difficult, but I'm working on it. *

Trying to change is pretty much a waste of time for me because the problem doesn't have to do with me. *

I'm hoping that I will be able to understand myself better. *

I guess I have faults, but there's nothing that I really need to change. *

I am really working hard to change. *

I have a problem and I really think I should work on it. *

I am not following through with what I had already changed as well as I had hoped, and I want to prevent a relapse of the problem. *

Even though I'm not always successful in changing, I am at least working on my problem. *

I thought once I had resolved the problem I would be free of it, but sometimes I still find myself struggling with it. *

I wish I had more ideas on how to solve my problem. *

Maybe someone or something will be able to help me. *

I may need a boost right now to help me maintain the changes I've already made. *

I may be part of the problem, but I really don't think I am. *

I hope that someone will have some good advice for me. *

Anyone can talk about changing; I'm actually doing something about it. *

All this talk about psychology is boring. Why can't people just forget about their problems? *

I'm struggling to prevent myself from having a relapse of my problem. *

It is frustrating, but I feel I might be having a recurrence of a problem I thought I had resolved. *

I have worries but so does the next guy. Why spend time thinking about them? *

I am actively working on my problem. *

After all I had done to try to change my problem, every now and then it comes back to haunt me. *

PROGRAM APPLICATION

Justice involved background

Educational Background

Values Survey

Please rank the following items 1-4 using the following scale: 1. Not important 2. Somewhat important 3. Very important 4. Extremely important

Assessment