Courts Pre-Sentence Investigation Report

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Statement from the State of Michigan Department of Corrections Your case has been referred to the Probation Department for purposes of conducting a Pre-Sentence Investigation for the Court. Your cooperation is necessary as all the information provided to our department must be verified for accuracy.

Please call (269) 657-8214 Monday - Friday between 8 AM and 5 PM to make an appointment with a pre-sentence investigator. You MUST call to set up your appointment within 24 hours of taking your plea.

Please immediately fill out your pre-sentence questionnaire. You will be given instructions on how to return the questionnaire by the pre-sentence investigator.

Failure to provide necessary information or failure to keep an appointment may result in the cancellation of your bond and may affect the outcome of your sentencing. You are expected to comply with the scheduling of your interview either electronically or in person. If a problem should arise, you must notify the Probation Department immediately.

Please be prepared for your interview by collecting and providing any/all available documents listed below to the agent at the time of your interview.

1. Driver's license, state identification or other valid picture identification

3. Social Security card 4. Pay stub or letter from your employer on letterhead 5. Proof of monthly state assistance information (ADC, SSI, Etc 6. Diploma or GED and/or current report card if

7. Certificates or degrees earned from vocational school, trade school, or college 8. Letters verifying dates of substance abuse/mental health counseling 9. AA/NA attendance sheets 10. Proof of military service
Please fill out this form completely. Your submitted form will be sent to the Van Buren County Probation Office. The following information will be used in the Pre-Sentence Report. It is confidential. You must answer it accurately and completely, do not skip any sections or it may lengthen your interview time. If you do not know part of the information requested, fill in what you do know and you can bring the additional information with you at the time of the interview.
- Name*
  
  First NameLast Name
- Previous names including maiden, street, gang, nicknames or aliases:
- Birth Date*
  
  MonthDayYear
  Date
- Birth City*
- Birth State*
- Birth country*
- Are you a US Citizen?*
  
  YesNo
- Social Security*
- Drivers license or state ID #
- Is you license valid?
  
  YesNo
- Residential Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Whom Do You Live With
- Date you moved in
  
  MonthDayYear
  Date
- Do you receive mail here?
  
  YesNo
- If not, provide your mailing address.
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Home phone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Message phone
  Format: (000) 000-0000.
- Name of phone owner
  
  First NameLast Name
- Email address
  example@example.com
- Eye color
- Hair color
- Race
- Religion
- Marital status
- Number of dependents
- Weight
- Height
- Dominate hand?
  
  RightLeftAmbidextrous
- Do you wear:
  
  GlassesContactsNeitherOther
- List any identifying scars, marks, tattoos, or amputations. For each mark, select the type, indicate where it is located on the body, and provide a brief description. Click “Add Another Mark” to list more than one.
- Have you been on probation or parole in the past?
  
  YesNo
- If yes where
- Explain
- Name of agents
- What was your age at first arrest
- Other Criminal Charges pending?
  
  YesNo
- If yes, what are the charges and where?
- If you have lived in any other states since the age of 16 list each city and state.
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- If deceased when and cause
- Past trouble/probation/parole:
- Name
  
  First NameLast Name
- Maiden or previous names
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- If deceased when and cause
- Past trouble/probation/parole
- Was either parent married before?
  
  YesNo
- Which one
- To whom and when
- If your parents are divorced, list the name of your step- father or step-mother. Step-father: Age:
- Are Your Parents Divorced?*
  
  NoYes, but not remarriedYes, and I have a step-parent
- I have a:
  
  Step-MotherStep-FatherBoth
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- If deceased when and cause
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- If deceased when and cause
- Past trouble/probation/parole
- List brothers and sisters or other significant family members:
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment
- Type of job
- Past trouble/probation/parole
- Are you:
  
  SingleMarriedWidowedDivorcedEngagedOther
- If you are unmarried but living with a significant other list their information.
  
  First NameLast Name
- Maiden name
- Date of marriage
  
  MonthDayYear
  Date
- Birth date
  
  MonthDayYear
  Date
- Age
- City and State of marriage
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment
- Education Highest grade completed
- How old were you at the time of the wedding
- How old was he or she
- Were you or your spouse ever pregnant?
  
  YesNo
- Have you ever separated?
  
  YesNo
- If divorced date of divorce
  
  MonthDayYear
  Date
- Who started the proceedings
- Why?
- Ex-spouses Name
  
  First NameLast Name
- Maiden name
- Date of marriage
  
  MonthDayYear
  Date
- City and State of marriage
- Age
- Birth date
  
  MonthDayYear
  Date
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment
- Education Highest grade completed
- How old were you at the time of the wedding
- How old was he or she
- Were you or your spouse ever pregnant?
  
  YesNo
- Date of divorce
  
  MonthDayYear
  Date
- Who started the proceedings
- Why?
- Ex-spouses Name
  
  First NameLast Name
- Maiden name
- Date of marriage
  
  MonthDayYear
  Date
- City and State of marriage
- Age
- Birth date
  
  MonthDayYear
  Date
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment
- Education Highest grade completed
- How old were you at the time of the wedding
- How old was he or she
- Were you or your spouse ever pregnant?
  
  YesNo
- Date of divorce
  
  MonthDayYear
  Date
- Who started the proceedings
- Why?
- If you are male, is anyone currently pregnant by you?
  
  YesNoOther
- If you are female, are you pregnant?
  
  YesNoOther
- If so who, is the partner?
- Due date
  
  MonthDayYear
  Date
- List sons and daughters (oldest first, also list step- children):
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Sex of child
  
  MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Telephone
  Format: (000) 000-0000.
- Cell phone
  Format: (000) 000-0000.
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- Are you required to pay Child Support?
  
  YesNo
- How much per week?
- Are you up to date?
  
  YesNoOther
- Other Parents Name
  
  First NameLast Name
- Birth date
  
  MonthDayYear
  Date
- Age
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Place of employment or school
- Education Highest grade
- # of children
- Husband or wife
- What is the longest period of time you have ever held one job
- Which job
- List your last five (5) jobs, beginning from present job: Name of employer:Telephone:
- Name of employer
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Supervisor or foremans name
  
  First NameLast Name
- Wage per hour
- Type of job
- Reason for leaving
- What shift do/did you work
- Type of employment
  
  Full timePart time
- Time In
  
  Hour Minutes
  
  AM/PM Option
- Time Out
  
  Hour Minutes
  
  AM/PM Option
- What is the longest period of time you have ever held one job
- Which job
- List your last five (5) jobs, beginning from present job: Name of employer:Telephone:
- Name of employer
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Supervisor or foremans name
  
  First NameLast Name
- Wage per hour
- Type of job
- Reason for leaving
- What shift do/did you work
- Type of employment
  
  Full timePart time
- Time In
  
  Hour Minutes
  
  AM/PM Option
- Time Out
  
  Hour Minutes
  
  AM/PM Option
- What is the longest period of time you have ever held one job
- Which job
- List your last five (5) jobs, beginning from present job: Name of employer:Telephone:
- Name of employer
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Supervisor or foremans name
  
  First NameLast Name
- Wage per hour
- Type of job
- Reason for leaving
- What shift do/did you work
- Type of employment
  
  Full timePart time
- Time In
  
  Hour Minutes
  
  AM/PM Option
- Time Out
  
  Hour Minutes
  
  AM/PM Option
- What is the longest period of time you have ever held one job
- Which job
- List your last five (5) jobs, beginning from present job: Name of employer:Telephone:
- Name of employer
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Supervisor or foremans name
  
  First NameLast Name
- Wage per hour
- Type of job
- Reason for leaving
- What shift do/did you work
- Type of employment
  
  Full timePart time
- Time In
  
  Hour Minutes
  
  AM/PM Option
- Time Out
  
  Hour Minutes
  
  AM/PM Option
- What is the longest period of time you have ever held one job
- Which job
- List your last five (5) jobs, beginning from present job: Name of employer:Telephone:
- Name of employer
- Telephone
  Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Supervisor or foremans name
  
  First NameLast Name
- Wage per hour
- Type of job
- Reason for leaving
- What shift do/did you work
- Type of employment
  
  Full timePart time
- Time In
  
  Hour Minutes
  
  AM/PM Option
- Time Out
  
  Hour Minutes
  
  AM/PM Option
- Branch of service
- Entry date
  
  MonthDayYear
  Date
- Discharge date
  
  MonthDayYear
  Date
- Type of discharge
- Highest rank held
- Status
  
  ActiveInactiveOther
- School name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Dates attended from to
  
  MonthDayYear
  Date
- Area of study
- Date graduated or dropped out
  
  MonthDayYear
  Date
- Certificate or degree
- School name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Dates attended from to
  
  MonthDayYear
  Date
- Area of study
- Date graduated or dropped out
  
  MonthDayYear
  Date
- Certificate or degree
- School name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Dates attended from to
  
  MonthDayYear
  Date
- Area of study
- Date graduated or dropped out
  
  MonthDayYear
  Date
- Certificate or degree
- School name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Dates attended from to
  
  MonthDayYear
  Date
- Area of study
- Date graduated or dropped out
  
  MonthDayYear
  Date
- Certificate or degree
- List any extracurricular activities you participated in while in school:
- Did you ever skip school?
  
  YesNo
- How often
- Were you ever suspended?
  
  YesNo
- When
- Why?
- Were you ever expelled?
  
  YesNo
- When
- Why
- If you dropped out of school explain why
- What if any are your plans for furthering your education
- Check any that apply.
  
  AlcoholMarijuanaCocaine or CrackAmphetamines, Meth, or SpeedBarbiturates, DownersHallucinogens, LSD, PCP, MushroomsHeroinPrescription DrugsOther
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Type of Drug?
- Age of first use
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Frequency
- Amount used
- Do you feel you need treatment now?
  
  YesNo
- Have you ever injected drugs?
  
  YesNo
- What is the longest length of time that you have been drug free?
- Which of your family members have had problems with drugs or alcohol?
- Have you ever received drug or alcohol treatment in the past?
  
  YesNo
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Type:
  
  AA/NA/Self HelpAssessmentDetoxificationDidacticDual DiagnosisEducationalIntensive OutpatientMethadone DetoxificationOutpatientResidential
- Start date
  
  MonthDayYear
  Date
- End date
  
  MonthDayYear
  Date
- Provider
- Completed?
  
  YesNo
- Notes:
- Do you have any serious mental health problems?
  
  YesNo
- If so please list
- Are you receiving disability benefits or workers' compensation?
  
  YesNo
- Are you currently taking prescription medications?
  
  YesNo
- If yes which ones and why were they prescribed
- Do you have health insurance or Medicaid?
  
  YesNo
- If so what is the companys name
- Have you ever been seen by a psychologist or psychiatrist?
  
  YesNo
- When
- Where
- How do you support yourself
- List all income you receive including partners or parents from whom how much
- Are you receiving public assistance? (ADC, etc.)
  
  YesNo
- Do you receive unemployment benefits?
  
  YesNo
- If so what type
- How much per month
- Why
- Caseworkers name
- Case #:
- Do you have any savings?
  
  YesNo
- How much
- Where
- Do you own your own home?
  
  YesNo
- Are you?
  
  BuyingRenting
- Rent or house payment monthly amount
- Do you live with your parents?
  
  YesNo
- Do you pay room & board?
  
  YesNo
- How much
- Per:
  
  WeekBi-WeeklyMonth
- Do you have a vehicle?
  
  YesNo
- If so give the year model make and color
- License plate
- If you are buying the vehicle what is the monthly payment amount
- If you do not have a vehicle describe the vehicle that you drive
- Who owns the vehicle
- Do you own any other motor vehicles, boats, motorcycles, RVs, etc.?
  
  YesNo
- If so, List here:
- Do you have anything valued over $1500.00
- List all debts, including credit cards:
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Date of arrest
  
  MonthDayYear
  Date
- Police Department
- Did you have an attorney?
  
  YesNo
- Offense
- Sentence
- Did you ever or do you currently belong to a gang?
  
  YesNo
- Gang name:
- Gang rank or position/level:
- Present offense:
- Name of your Attorney
- Appointed or retained?
  
  AppointedRetainedOther
- Please describe the present offense in your own words. What did you do? What happened?
- Why did you get involved?
- Include any other information that the Judge should know or consider:
- Please verify that you are human*
- Signature
- Receive an Email Copy of this form?
  
  YesNo
- Email address
  example@example.com
- Should be Empty: