Probation Candidate Demographic Form
Our goal is to help you succeed while on probation, to better your life, and not return to the criminal justice system. Please let us know if you have any questions regarding this process.Please fill out this form in its entirety. Be honest, accurate and answer all questions completely and to the best of your ability.
Section 1: Personal Information
Name
First Name
Middle Name
Last Name
Have you used any other names/aliases/nicknames?
Yes
No
If yes, please list:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email, primary
example@example.com
Email, other
example@example.com
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Birth Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
Caucasian(White)
African American
Hispanic
American Indian
Asian
Pacific Islander
Alaskan Native
Other
Primary Language:
English Translator Required?
Yes
No
Driver's License
Yes
No
If Yes, Driver License Issuing State:
Driver License Number:
If No, Please Explain:
Driver's License Valid?
Yes
No
If No, Please Explain:
Section 2: Additional Personal Information
Height:
Weight in lbs:
Eye Color:
Hair Color:
Scars/Masks/Tattoos:
Serious Medical Condition:
Yes
No
If Yes, Explain:
Insulin Dependent:
Yes
No
Seizure:
Yes
No
History of mental illness:
Yes
No
If Yes, Please Explain:
Physical handicap:
Yes
No
If Yes, Please Explain:
Registered Sex offender:
Yes
No
Anger Management Issues:
Yes
No
If Yes, Please Explain:
Military service:
Yes
No
If Yes, Are you a combat Veteran?
Yes
No
Dates of Service From:
-
Month
-
Day
Year
Date
Dates of Service To:
-
Month
-
Day
Year
Date
If no longer active, reason for discharge:
If you have been discharged, please upload a copy of your DD-214 here or provide a copy to staff.
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Section 3: Family Information
Marital Status:
Married
Single
Separated
Divorced
Widow(er)
Partner
If Married or Living with Partner please provide their information:
First Name
Last Name
Age:
Phone Number:
Do you have previous spouse(s)?
Yes
No
If Yes, List previous Spouses:
Do you have child(ren) (adult or minor)?
Yes
No
List immediate family members (other than children and spouse listed above):
List immediate family members (other than children and spouse listed above):
Section 4: Transportation Information
Primary means of transportation (select all that apply):
Private Vehicle
Public Transportation
Bicycle/Foot
Family
Friends
Other
If family, friends, or other checked provide names or description of other:
Do you own a vehicle?
Yes
No
List immediate family members (other than children and spouse listed above):
Section 5: Residence & Living Information
How long have you lived at this address?
Type of housing:
Single Family Dwelling
Condo
Apartment/Duplex
Trailer Home
Transient
Do you own, rent, lease or none?
Own
Rent
Lease
None
Does anyone else live/stay here with you? Other than child, spouse, or partner listed above, list all who live/stay with you at this address.
Yes
No
If Yes, list:
Do you stay anywhere else?
Yes
No
Where do you stay? (List Locations)
Residential Past History List: List in chronological order, from present to past, all addresses where you have resided in the past 5 years. Use the month and year for the “From” and “To” dates:
Section 6: Employment
Are you currently employed?
Yes
No
If not, Explain why:
If yes provide employer information:
Employer Name:
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date Hired:
-
Month
-
Day
Year
Date
Status:
Full-time
Part-Time
Hours per week:
Work Schedule:
Supervisor Name:
First Name
Last Name
Supervisor Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisor Email:
example@example.com
Employment History:
Section 7: Questions
What was your age at first arrest?
18 or younger
19-22 years old
23 or older
How many times have you been arrested(including juvenile arrests)?
10 or more
4-9 times
0-3 times
What is your current age range?
18-30 years old
30-44 years old
45 or older
Do you have a high school diploma, equivalent or GED?
Yes
No
Do you own or possess any firearms or ammunition?
Yes
No
If yes, please list all of them and the reason for possessing:
Does the current case you are on probation for directly or indirectly involve the use and/or possession of drugs and/or alcohol?
Yes
No
If yes, please explain:
Have you ever been charged or arrested for a domestic violence related offense?
Yes
No
If yes, please explain:
Other than your current probation offense, do you have any other felony or misdemeanor charges in Utah or a different state?
Yes
No
If yes, list Charges and Locations:
Do you have any pending cases in Utah or a different state?
Yes
No
If yes, list Charges and Locations:
Do you have any short term goals (3-6 months)?
Yes
No
If yes, List the top 2 short term goals:
Short term Goal 1
Short term Goal 2
Do you have any long term goals (1-2 years)?
Yes
No
If yes, List the top 2 long term goals:
Long term Goal 1
Long term Goal 2
Please briefly tell us about what happened that led to your current probation:
Section 8: Drug, Alcohol, & Tobacco Use
Answer the questions below concerning your primary, secondary and third choice for drug and/or alcohol use.
Primary Choice
Type of drug or alcohol?
Age first used?
How often do you use?
How do you use (inject, inhale, oral, smoke)?
Date last used?
Days used in the last 30 days?
Who do you use with?
Second Choice
Type of drug or alcohol?
Age first used?
How often do you use?
How do you use (inject, inhale, oral, smoke)?
Date last used?
Days used in the last 30 days?
Who do you use with?
Third Choice
Type of drug or alcohol?
Age first used?
How often do you use?
How do you use (inject, inhale, oral, smoke)?
Date last used?
Days used in the last 30 days?
Who do you use with?
Total cost of habit per day:
Total years of use:
Total drinks per day:
Do you smoke?
Yes
No
If yes how many packs per day?
Do you chew?
Yes
No
Are you in alcohol or drug treatment?
Yes
No
If yes, please specify:
Are you abusing prescription drugs?
Yes
No
If yes, please specify:
Agreement and Signature
Signature
Date
-
Month
-
Day
Year
Date
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