Language
English (US)
Spanish (Latin America)
Dubois County Pretrial Services
Pretrial Monitoring Electronic Check-In Form
Participant Name
*
First
Middle, if any
Last
Suffix, if any
Date of Birth
*
-
Month
-
Day
Year
Last 4 Digits of your Social Security Number
I do not have a social security number
Current Address
Street Address
Street Address Line 2 (Apartment or Lot Number, for example)
City
State / Province
Postal / Zip Code
I am homeless.
Email Address
example@example.com
I do not have an email address.
Current Phone #
I do not have a phone.
Have you been receiving text alerts for your upcoming Court hearings?
*
Please Select
Yes
No
Date of Next Court Hearing
-
Month
-
Day
Year
Time of Next Court Hearing
Hour Minutes
AM
PM
AM/PM Option
I do not know the date & time of my next Court hearing.
Have you been charged with any new criminal offenses since your last check-in?
*
Please Select
Yes
No
If yes, where and when?
Date of Next Face-to-Face Meeting with Pretrial Services Staff
-
Month
-
Day
Year
Time of Next Face-to-Face Meeting with Pretrial Services Staff
Hour Minutes
AM
PM
AM/PM Option
I do not remember the date & time of my next Face-to-Face Meeting
Do you need to speak with a staff member prior to your next Face-to-Face Meeting?
*
Please Select
Yes - Please call me
Yes - Please email me
No
Case Manager
*
Please Select
Christina Wagner
Danielle Traylor
Kim Johnson
Jenny Fowler
If you need to speak to your case manager, briefly describe the reason.
Please verify
*
Submit
Should be Empty: