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Client Eligibility Survey

This form gives Parole Project staff relevant information related to a potential client. Completion of this form does not guarantee acceptance into Parole Project’s program.

Step 1 of 2

50%

Contact Information

Parole Project staff may need to contact you regarding this questionnaire or other necessary information.

Your Name(Required)

First Last

Your Email(Required)

Your Phone Number(Required)

How can we get in touch with you if we need more information?(Required)

Call me

Email me

The best time to contact me is…(Required)

Your relationship to the incarcerated person(Required)

Potential Client Information

The following information is required to identify a potential client’s eligibility. Please answer as accurately as possible.

Name(Required)

First Middle Last

DOC Number(Required)

If you do not know the individual’s DOC number, please enter “00000”

Incarcerated Person's Date of Birth(Required)

If you do not know their date of birth, enter today’s date.

MM slash DD slash YYYY

Name of Prison(Required)

How many years has the individual been incarcerated?(Required)

Is the incarcerated person you are inquiring for a citizen of the United States?(Required)

Yes

No

I’m not sure

Is the incarcerated person you are inquiring for housed at a Louisiana prison?(Required)

NOT a jail or federal institution

Yes

No

Has the incarcerated person obtained a high school equivalency degree while incarcerated?(Required)

Yes

No

No, but they have obtained a special education waiver

I’m not sure

Has the incarcerated person completed the mandatory DOC 100 Hours Pre-Release Program?(Required)

Yes

No

Currently Enrolled

On Waitlist

Check all that apply to the incarcerated person's situation(Required)

They already have a parole hearing date

They were denied parole in the past

They are working with an attorney to be resentenced

They are eligible for parole but have not been put on the docket

They aren’t eligible for parole at this time but hope to be eligible in the near future

They are waiting for the Governor to sign a clemency application

Their sentence has been commuted and they will be going before the board

They are nearing their full time or good time release date

Hearing Date(Required)

MM slash DD slash YYYY

What crime was the incarcerated individual convicted of?(Required)

Age at conviction(Required)

What parish was the incarcerated individual convicted in?(Required)

If you do not know, please select “I’m not sure” at the bottom of the list.

What is the incarcerated person's sentence?(Required)

Was the incarcerated person ever charged as a juvenile?(Required)

For any crime other than the current sentence

Yes

No

I’m not sure

Does the person you are inquiring for have an attorney?(Required)

Yes

No

Attorney Name(Required)

Attorney's Law Firm(Required)

What are the incarcerated person's long-term residential and employment plans?(Required)

Additional Information

Δ

P.O. Box 2029
Baton Rouge, LA 70821
319 Third St.
Baton Rouge, LA 70801
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Client Eligibility Survey