Intake Questionnaire

April 7, 2008

All information provided on this form is confidential and will not be shared unless your express permission is given.

Your Contact Information

Title *

First Name *

Last Name *

Inmate ID Number

ONLY include Inmate ID number if CURRENTLY incarcerated

Street Address - line 1 *

Street Address - line 2

State

City

Zip Code *

Primary Phone Number *

Include area code. Do NOT include symbols, e.g. 7751234567

Alternate Phone Number

Include area code. Do NOT include symbols, e.g. 7751234567

Email Address

If you provide an email address, you will receive an email confirming that this complaint was successfully submitted.

I give permission to the ACLU to contact me via email about the status of my complaint *

Yes

No

If you check “no” you will receive correspondence via the U.S. Mail

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