PROBATION CLIENT INFORMATION SHEET

PROBATION CLIENT INFORMATION SHEET
Date*

MonthDayYear
Date
Offense*
Judge Parker or Judge Brady*

Judge ParkerJudge Brady
DEMOGRAPHICS
Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Address

Street Address Line 2

CityState

Zip Code
How long have you lived at this address*
Living with*
Date of birth*

MonthDayYear
Date
Age*
Preferred pronouns/identifies as:*
Place of Birth (State or Foreign Country)*
U.S. Citizen*

YesNo
Last 4 digits of Social Security*
Drivers License #
Relationship Status: Married: # of years
Relationship Status: Divorced # of years
Relationship Status: Single/Widowed/Separated

SingleWidowedSeparated
Spouse/significant other name
# of children and their ages
EDUCATION:
High School
Graduation Year
Highest grade completed
GED
College
Graduation Year
Degree/certifications
Military:
Branch
Years
Rank
Discharge
EMPLOYMENT:
EMPLOYMENT Bring your most recent pay stub to document employment
Date of employment *

MonthDayYear
Date
Name of Employer & Title *
Address of employment *
Hours/ Wages*
Date of employment

MonthDayYear
Date
Name of Employer & Title
Address of employment
Hours/ Wages
Do you receive any financial assistance?*

YESNO
Do you recieve SSI SSD Bridge Card food assistance cash assistance housing assistance child support? List amounts*
List all monthly bills and amounts - for determining payment plan
Mortgage/Rent *
Utilities *
Car Loan*
Medical Bills *
Credit Card *
Loans*
HEALTH:
Heath Insurance Provider*
General Condition of Health:*

GoodFairPoor
Mental health diagnosis or conditions*
Medications/vitamins/supplements*
Have you ever attended treatment in the past: (outpatient, inpatient, education/12 step meetings):*

YESNO
Where
Are you currently in treatment for substance abuse or mental health counseling:
Agency*
Therapist/Psychiatrist*
Please provide any counseling you are participating in or have recently completed to your appointment.
SUBSTANCE USE HISTORY:
Alcohol: Frequency of use per week/month
Alcohol: Age of first use
Alcohol: Date of last use
Alcohol: Reason for use and/or family history
Marijuana: Frequency of use per week/month
Marijuana: Age of first use
Marijuana: Date of last use
Marijuana: Reason for use and/or family history
Crack/Cocaine: Frequency of use per week/month
Crack/Cocaine: Age of first use
Crack/Cocaine: Date of last use
Crack/Cocaine: Reason for use and/or family history
Heroin: Frequency of use per week/month
Heroin: Age of first use
Heroin: Date of last use
Heroin: Reason for use or family history
Prescriptions drugs (such as Xanax, Norco, Klonopin, OxyContin, Fentanyl, Percocet, Adderall): Frequency of use per week/month
Prescription drugs: Age of first use
Prescription drugs: Date of last use
Prescription drugs: Reason for use and/or family history
Other: Frequency of use per week/month
Other: Age of first use
Other: Date of last use
Other: Reason for use and/or family history
LAW ENFORCEMENT CONTACT
Date

MonthDayYear
Date
Offense
Place/City
Sentence
Date

MonthDayYear
Date
Offense
Place/City
Sentence
Date

MonthDayYear
Date
Offense
Place/City
Sentence
Date
Offense
Place/City
Sentence
Are you currently on probation or parole?*

YESNO
Court
Charge
Pending case?*

YESNO
Court
Charge
Do you own/possess any weapons?*

YESNO
Emergency Contact:
Name and Relationship*
Phone number*
Explain the details of the events that happened on the day of the incident you were arrested or ticketed for (For alcohol related offenses include where you were coming from what type of alcohol you consumed the amount length of time and where and why the consumption took place).*
Any facts/circumstances you would like the Judge to consider prior to sentencing:*
Please sign and date below to acknowledge the above information in the entirety of this document is true to the best of your knowledge.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

PROBATION CLIENT INFORMATION SHEET

DEMOGRAPHICS

EDUCATION:

Military:

EMPLOYMENT:

List all monthly bills and amounts - for determining payment plan

HEALTH:

SUBSTANCE USE HISTORY:

LAW ENFORCEMENT CONTACT

Emergency Contact: