Serving the Fox Valley, Green Bay, Oshkosh and surrounding communities.
A Program of Goodwill NCW

Part 2 – Intake Information

Before a participant comes to the Circle meetings, a volunteer completes an intake interview with that person. We are especially in need of volunteers who are willing to be trained in this duty. PLEASE let Anne or your group leader know you would like to learn how to do intakes if you are interested.



Participant Criteria

  • Primary preference shall be for offenders on DCC supervision recently released from prison and on Parole/Extended Supervision.
  • Secondary preference shall be for offenders on DCC supervision on DCC supervision recently released from County Jail.
  • Male and Female participants accepted
  • Voluntary participation
  • Behavioral history/patterns of sex offenses and/or assaultive acts will be reviewed individually for participation.
  • Current Circles participants who have been released from Supervision may continue to attend the Circle meetings as visitors

Referral Process

  1. Supervising Agent may refer an offender to the Director of the Circles of Support via email or telephone by providing the offender’s name, DOC number, location, and a brief description of the offense and needs upon release.
    If the offender is in a Correctional Institution, the referral is preferred approximately 10 days prior to release.
  2. When referrals are received, the supervising agent will be contacted for referral information and input regarding the offender’s participation as well as for a Form 1336 to allow Circles to provide resources).
  3. If the offender is incarcerated, a letter (copied to the Institution Social Worker and Agent) and application will be sent to the offender to determine interest in participation.
  4. If the offender indicates an interest in participating in Circles by returning the application, the Social Worker and Agent will be asked to have the offender sign a DOC Confidential Release of Information to the Community Circles of Support. This will allow review of any relevant case file information and communication between DOC staff and Circles members.
  5. The Circles Director and Group Leader will decide whether to accept the offender for the program.
    The Volunteer Group Leader, and Social Worker and/or Agent will be notified.
    The offender should be contacted by a Volunteer to set up an Intake Interview within 7 days of application and invited to a meeting.

Individuals NOT on Supervision with the DOC

  • DOC funded resources are only available to participants currently on supervision with the DOC

Unexpected Walk-Ins to COS Group Meetings

  • Group facilitators should speak privately with the individual, obtaining his/her name and Agent’s name, if applicable, and how they were informed about COS. From the discussion, a judgment call can be made to invite them to sit in the COS meeting (especially if their agent has informed them about COS) and after the meeting give them a referral application to complete. If the decision was not to invite the individual to sit in, give them the Vocational Coordinator’s phone number to call or a referral application that they can fill out and give to the facilitator or take with them. M Contact the COS Vocational Coordinator as soon as possible with the individual’s name and reason/concern for not inviting them to attend the meeting.

Suggestion: If there is something noticeably objectionable, smell of alcohol, no connections with DOC, alone or not accompanying a participant, it would be advisable to not allow them to sit in, but to give the person the Vocational Coordinator’s phone number to call for information regarding the programs criteria.



1. PURPOSE: to inform potential participant of Circles of Support Program content, expectations and guidelines and to obtain relevant information from participant to help develop a plan for success.


  1. Introductions and explanation of purpose of interview.
  2. Ask how they heard about Circles, give brochure, review highlights of brochure with stress on:
    1. It is voluntary and focuses on strengths
    2. Helps to connect with existing resources
    3. Focuses on future, not past
    4. Goal setting
  3. Explain how they can be involved-groups/individual-stress flexibility.
  4. Review participant pledge-give them a copy
  5. Review and sign release
  6. Using participant information form-ask questions to give general description of participant and their situation-citing strengths, current relationship with community resources, id current need areas.
  7. Complete referral Checklist form
  8. Review informational sheets generally
    1. Basic needs resources: Give copy of 2-1-1 brochure (FV Brochure, Oshkosh Brochure, Green Bay On-line database) and explain.
    2. List of Temp Agencies: ID the more frequently used.
    3. Stress involvement with the Job Center, especially services for ex-offenders.
    4. Copy of potential landlords
    5. Copy of meeting schedule
    6. Copy of Affordable Care Act, and stress importance to register.
    7. Phone number where they can contact you if necessary
  9. Review Plan for Success Process:
    1. ID area that have presented most problems in past
    2. Have participant ID strengths he/she has in this area now.
    3. Have participant ID things need to be done to succeed
    4. Go through process with two other areas.
    5. Have participant take home and finish all areas
    6. Use at next individual session to identify sort term goals that need to be accomplished.
    7. ID areas of immediate need and make referrals/provide appropriate practical information
      1. Food
      2. Medical
      3. Clothes
      4. Bus Tickets
      5. Bike
  10. Set follow-up appointment to finalize plan and to decide how participant will be involved.
  11. Send or deliver copy of referral check sheet, release of info, application, plan for success, participant info worksheet to the Circles director’s office as soon as possible.
  12. Give copies of participant pledge, release of info, and plan for success to participant.
  13. Things to keep in mind
    1. Stay focused
    2. Explain what follow up sessions will be like
    3. Important to help them see how Circles can be of help
    4. Keep goal setting short term
    5. If you can’t answer questions raised, get back to them.


*Intake packets are at the volunteer desk at the GW campus or with your group leader.

Rev. 1/2016


A program of Goodwill NCW


APPLICANT: Please answer the following questions completely and return to:

CIRCLES OF SUPPORT, 1800 Appleton Rd., Menasha, WI 54952

Or email to: mailto:[email protected]




Name:                                                                                                                                  ________

Date Applied:                                                    

Address: ____________________________________________

City/Zip: _________________________

Is this a TLP? _____  If not, what is your living situation? (parent/friend/pay own rent) _______________

Telephone or contact numbers: ___________________________________________________________

Date of Birth:                          Race:__                   Male/Female/TransG (circle one)   DOC#________________

Release Date from prison:                                      Have you been jailed since release from prison?___________

DOC Agent: ________________________________________________ City:_______________________

Most recent Conviction/Sentence (if you were just released because of revocation please list original offense as well): __________________________________________________________________________________

What other crimes have you been incarcerated for: ___________________________________________ _____________________________________________________________________________________

Number of times incarcerated: __________ Do you have pending cases? __________________________

Do you have mental health issues? (anxiety, depression, bi-polar, etc.)____________________________

Are you employed?_________   Source of income?_____________________  SSI/SSDI eligible?________

Community releasing to (circle one):  Appleton   Neenah/Menasha   Oshkosh   Green Bay

Are you a Veteran?____  If so, have you accessed services and if not, why not?_____________________



Describe a time in your life when you felt good about something you accomplished and how you achieved it.





What are three goals you want to accomplish within the next six months when you return home?





Are you coming to Circles of your own free will? If no, please explain.





How did you find out about Circles and what do you believe Circles can do to help you?






A program of Goodwill NCW

Intake Referral Checklist


Participant Name_______________________________________________ Date___________________

Interviewers: Please fill out entire intake package INCLUDING the Participant Info Form

The following resources and information were reviewed/assessed/discussed with this participant:

  • Basic Needs Resource Sheet
  • Education
  • Housing Information Sheet
  • Driver’s License
  • Goodwill Employment Experience Program
  • W-2 Program
  • FoodShare/FSET
  • Personal Finance Counseling
  • Veteran’s Services
  • American Indian Center
  • Physical/Mental Health Needs & Services
  • AODA Needs & Services
  • Family Counseling
  • Social Skills Development
  • Leisure Activities
  • Participant Pledge/Release of Information/DOC Waiver

NA – Not Applicable (enter NA if the Participant indicates no need for or interest in a particular area)

Participants will also be assisted by Circles volunteers in attaining their needs from referrals, as necessary.


A program of Goodwill NCW



Please print clearly and large enough so we can read. Thanks!



Full Legal Name __________________________________________________Phone________________

DOC #______________________ DOB___________ RACE_________ GENDER______ VETERAN_______

Participant’s Address _________________________________________________TLP?_______________

If not TLP, what is your living situation? (Friends?/Family?/Pay rent?) ____________________________

Last Date of Release from jail/prison _______________ Institution released from: __________________

Supervising Agent _____________________________________ Phone ___________________________

Conviction/Sentence (If you were just released because of revocation please list original offense as well):


Prior Convictions/Sentences (including all sex offenses) ________________________________________


Education ____________________________________________________________________________

Work History/Skills _____________________________________________________________________

Are you presently working?_____ FT__ PT__  Where? _______________________________________

If not, what is your source of Income?___________________________ Eligible for SSI/SSDI?__________

Alcohol/Drugs/Other Addictions __________________________________________________________

Family and History _____________________________________________________________________


Physical/Mental Health Issues ____________________________________________________________


Valid DL                  ____ Health Ins.                                      Foodshare _________  Transportation ____________

Other Community Agency/Program Involvement _____________________________________________

RESOURCES GIVEN TO PARTICIPANT TODAY: _______________________________________________

(Volunteers: Please note resources given today on the monthly stats as well.)


A program of Goodwill NCW




  • Attend Circles of Support meetings for at least six months. Attend every week for eight weeks and at least twice per month thereafter. Individual sessions are available as well as phone contacts.
  • Accept responsibility for my past criminal behavior and acknowledge the harm my past behavior has caused others.
  • Put forth effort to work towards all mutually agreed upon Plan of Success recommendations.
  • Avoid talking about what other participants discuss within the Circles group to nonparticipants.
  • Not interfere with or confront Circles volunteers outside of the Circle activities under any circumstances. Circles volunteers pledge to do the same with participants.
  • Understand the volunteer members of the Circles of Support will maintain open communication, credibility, straightforwardness, and safe boundaries among participants, volunteers, and the Department of Corrections. This includes communication with the participant’s supervising agent. TRANSPARENCY IS KEY!
  • Understand that I personally assume all responsibility for the volunteer relationships between myself and other Circle members and participants. I agree to hold the Circles of Support and Goodwill NCW harmless for any actions of a participant, member or myself.

Updated: 8/6/15


A program of Goodwill NCW

Transitioning support from incarceration to the community

1800 Appleton Road, Menasha WI 54952-3729

Anne Strauch, Circles of Support Program Coordinator

[email protected] ◊ 920-968-6832 or 1-877-490-3120



I,                                                                                       , hereby authorize the release/exchange of information to the persons or agencies named below. I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the entity providing the information.


Persons/organizations with which information may be released/exchanged:

Name Agency Contact Info Signature of Participant
DCC Agent and/or other staff members Division of Community Corrections To assist in successful transition of participant
Circles of Support volunteers and/or GW staff, as needed. Goodwill Industries, NCW To assist in successful transition of participant


Information to be used or disclosed: Participation sharing in the Circle of Support Program

Purpose of the disclosure: To assist the above participant in successful transition to the community.


Important Information about Your Rights

  • I have read and understand the following statements about my rights.
  • I may revoke this authorization at any time prior to its expiration date by notifying either person/agency in writing, but the revocation will not have any effect on any actions the entity took before it received the revocation.
  • The information received by Circles volunteers will not be disclosed to another entity without an authorized release of information.




Signature of Participant                                                                      Date



Signature of Circle Member                                                                Date



A program of Goodwill NCW

Plan for Success

Name _____________________________________________________                Date _____________________

Which Circles group _________________________ Circle Representative _________________________

Volunteer Comments ___________________________________________________________________

Identify areas of immediate need or personal goals over the term of this Plan. Then identify any Strengths you have in each particular area, and the specific Action Steps you need to take to accomplish your Goals. Categories of need or interest may be included: Employment, Education, Personal Finance/Budgeting, Substance Abuse (living without reliance on alcohol and/or drugs), Associates/Activities (positive interaction with non-criminal associates), Basic Needs (food, clothing, etc.), Medical Health (physical, emotional, mental, medications, etc.), Family, Transportation, Attitudes/Beliefs (living in law-abiding ways), and Community Functioning (leisure activities, volunteering, using local resources, etc.). Use numbers to prioritize as appropriate. This Plan should serve as an active personal roadmap for the Participant and should be revised or updated as often as needed.


(include Target Dates)





































































Rev. 3/19/15