Intake

Compassionate release intake form.

Tell us about your loved one so we can determine how we can help. There is no cost to submit this form, and we contact you within 2–3 business days.

Incarcerated individual

Full name *CDCR number *California Department of Corrections & Rehabilitation numberCurrent age *Date of birth *Year of incarceration *What year was the individual incarcerated?County of commitment *County where the sentence was imposed

Current California state prison facility *Where the individual is currently housed

Health & accessibility

ADA condition / disability *Physical, sensory, cognitive, or mobility disabilitiesMedical condition(s) *Diagnoses, treatments, and how the condition affects daily functioning

Family & contact

Your name *Relationship to the individual *Phone number *Email address *

Additional information

How did you hear about The Revive Project?Additional notes or questions

Privacy & consent. By submitting this form you consent to The Revive Project contacting you at the phone number and email address provided. Your information is kept confidential and used solely to provide compassionate release consulting services. The Revive Project, LLC is not a law firm and does not provide legal or medical advice.