Oxford House Indiana Re-Entry Intake

This form is for submitting completed Oxford House Indiana Re-Entry applications. Applications may be submitted by IDOC case managers, re-entry staff, referral partners, or other authorized support personnel.

Please upload the completed paper application as a PDF. After submission, the system will generate a Case_ID and route the application to Oxford Houses in the selected primary county.

Submitter Information

Submitted by role

Submitter Full Name

Submitter Email Address

Applicant Information

Applicant Full Legal Name

DOC Number/Case Number

Cause Number

Is the applicant currently incarcerated?

Facility name or "At Liberty"

Definite release date

Date of Release

Release Location / Routing

Primary County

Secondary County

Intended release city and/or county

Are alternate counties/chapters acceptable if placement is unavailable?

Alternate Acceptable County Choices

Case Manager / Supervision

Case Manager Name

Case Manager Email

Supervision Status Upon Release

Re-Entry Assistance

Will Re-Entry Assistance be requested?

Assistance Type

Amount Requested (USD)

Documents

Upload Completed Re-Entry Application (PDF)

Upload additional supporting documents (optional)