Clients NameName* First Last Gender*MaleFemaleTransgenderSBI#*Inmate#*Date of Birth* Special Needs*Handicap Accessible FacilityMental IllnessKnown Drug/Alcohol AbuseN/AUnknownLast Known Address* Street Address City State / Province / Region ZIP / Postal Code Release Date* Type of Release*Max OutParoleProbationPre-AdjudicatedUnconfirmedNACurrent Offense*Criminal History (Use Ctrl for multiple selection)*Drug DistributionSex OffenderArsonistNoneWill AttachHas the client ever used Emergency Assistance benefits for housing:* Yes No If so, How long?Additonal Notes:Attach FileAccepted file types: pdf, jpg, doc, xls, png, gif.Requester InformationName* First Last Facility Name:*Email* Phone:*Fax: