WCC Visitation and Orientation Form

Fill out the interactive form below, or print the PDF version of the form, fill it out and bring it to the Western Massachusetts Regional Women’s Correctional Center. The video below contains the rules and orientation information needed for visitation.

Play Video

Inmate Name(Required)

Inmate Date of Birth(Required)

Have you ever been incarcerated?(Required)

YES

NO

If previously incarcerated, in which state did you serve time?

Have you ever been convicted of a felony?(Required)

YES

NO

Do you have any open court cases?(Required)

YES

NO

Are you currently on Probation?(Required)

YES

NO

Is there an active Restraining Order between you and the above inmate?(Required)

YES

NO

Have you visited any other inmates here in the past?(Required)

YES

NO

If yes, name the inmate and list when the visit took place:

What is your relationship to the above inmate you are requesting to visit? *(Required)

For example: Wife, Mother, Sister, Daughter, Friend, etc.

My true name is:(Required)

First Last

My date of birth is:(Required)

My present address is:(Required)

My phone number, including area code, is:(Required)

Driver’s License Number:(Required)

My email address is:

Any additional comments or notes for HCSD staff: