Mohave County Adult Probation - Pre-Sentence Questionnaire

MOHAVE COUNTY ADULT PROBATION DEPARTMENT
PRE-SENTENCE INVESTIGATION QUESTIONNAIRE
PURPOSE OF THE PRE-SENTENCE INVESTIGATION REPORT (PSI):
To provide the Judge with sufficient information about a crime and your involvement in it so he can decide your appropriate sentencing. It will contain a summary of your offense; any statement(s) you make about it; your social history; and statement(s) provided by any victims, law enforcement officers, or anyone else involved with you or your case. It will also include your prior criminal and traffic records as well as any outstanding warrants found. You are NOT "on probation" just because you are completing this questionnaire. You are participating in the pre-sentence investigation process, which occurs in nearly all felony cases regardless of the possible sentence.
Your PSI will be prepared by a Deputy Probation Officer; a professional who has the education, training, and experience to understand and evaluate human behavior and criminal justice issues. The PSI writer is NOT an attorney: he/she represents the Court-NOT you or your attorney, nor the prosecuting attorney or the police. If your plea or conviction allows for at least the possibility of probation, the PSI writer will give the Judge an evaluation of your ability to successfully complete such a term. You may not agree with the PSI writer's opinions; however, he/she will make every effort to prepare as accurate, complete, and objective a report as possible in your case. Your attorney will review yours with you to determine whether any corrections or additions need to be given to the Judge in court.
Instructions for returning this questionnaire:
1) IF YOU ARE NOW IN JAIL: Complete the attached questionnaire and give it to a Detention Officer to be forwarded to the Probation Department. Your PSI officer may contact you through the jail telephone afterward to interview you. If you are released from jail before completing this questionnaire, see the paragraph below.
2) IF YOU ARE NOT IN JAIL: Complete the attached questionnaire and return it IN-PERSON to the probation office nearest to where you live (see locations at the bottom of this page). If you live outside of Mohave County, you may return this questionnaire by E-MAIL to the assigned officer or by FAX to the Kingman probation office.
3) BY MAIL: Send the questionnaire to Mohave County Probation, P.O. Box 7000, Kingman, AZ 86402-7000. You will be responsible for the cost of mailing. Be sure to consider the time needed for the postal service to deliver it. Use the above address; do not send any mail to the three office addresses at the bottom of this page.
Your PSI officer may contact you to review or clarify information you provide once he/she receives your questionnaire. If your attorney tells you not to answer any part of the questionnaire, let the PSI writer know that is why you did not fill out that portion. The final ruling has yet to occur in your case; failure by you to cooperate with the probation department in this investigation may weigh against you when the Judge decides your sentence.
Statements or documents on your behalf may be given to your attorney who can then provide them to the Judge.

Statements or documents on your behalf may be given to your attorney who can then provide them to the Judge.

Kingman (main office)	Bullhead City	Lake Havasu City
Mohave County Probation Dept. 809 E. Beale Street Kingman, AZ 86402-7000	Mohave County Probation Dept. 967 Hancock Road, Suite 25 Bullhead City, AZ 86442	Mohave County Probation Dept. 2001 College Drive, Suite 129 Lake Havasu City, AZ 86404
Phone: 928-753-0741 Fax: 928-718-5508	Phone: 928-758-0738 Fax: 928-763-8744	Phone: 928-453-0707 Fax: 928-855-1969

** DO NOT MAIL YOUR QUESTIONNAIRE TO THESE OFFICES - SEE ABOVE "RETURNING BY MAIL" **
STAY IN CONTACT WITH YOUR ATTORNEY for any changes to your sentencing date.

II. PHYSICAL HEALTH
YesNo
DO YOU HAVE ANY PHYSICAL HEALTH ISSUES OR LIMITATIONS THAT MAY CREATE DIFFICULTIES COMPLYING WITH THE CONDITIONS OF PROBATION? IF SO, EXPLAIN - INCLUDE DATE(S) OF DIAGNOSIS AND TREATMENT RECEIVED.
III. MENTAL HEALTH
YesNo
DESCRIBE ANY PAST/PRESENT MENTAL OR EMOTIONAL HEALTH ISSUES, INCLUDING DEPRESSION AND ANY SUCIDIAL THOUGHTS OR ATTEMPTS. INCLUDE DATE(S) OF DIAGNOSIS AND ANY TREATMENT/COUNSELING YOU RECEIVED OR ATTENDED.
YesNo
LIST ALL MEDICATIONS CURRENTLY SUBSCRIBED TO YOU:

VI. FINANCIAL

MONTHLY INCOME:

Rows	Amount
Monthly Income
Spouse's Income
Social Security Income
Gov't Assistance
Retirement
Child Support
Other

Total Monthly Income

MONTHLY EXPENSES:

Rows	Amount
Rent / Mortgage
Food / Clothing
Utilities
Medical Expenses
Vehicle Expenses
Credit Cards / Loans
Other

Total Monthly Expenses
YESNO
IF "YES", HOW MUCH?

ASSETS - LIST ALL OF YOUR MAJOR ASSETS: HOME, VEHICLES, PROPERTY, TOOLS, SAVINGS, ETC.:

Rows	ITEM AND ESTIMATED VALUE	FULLY-OWNED?	AMOUNT OWED:
1
2
3
4
5
6

DEBTS - LIST ALL MAJOR DEBTS: CREDIT CARDS, LOANS, CHILD SUPPORT, COURT FINES, ETC.

Rows	DESCRIPTION OF DEBT	BALANCE REMAINING	PAYING AS REQUIRED?
1
2
3
4
5
6

YESNO
WHEN?
CHAPTER:
HAVE YOU EVER BEEN AWARDED A FINANCIAL SETTLEMENT, INHERITANCE, OR OTHER LARGE SUM OF MONEY? IF SO, EXPLAIN:
IF PLACED ON PROBATION, HOW MUCH CAN YOU BUDGET FOR COURT-ORDERED MONIES (RESTITUTION, FINES, ATTORNEY FEES, PROBATION FEES, ETC.)? $

X. SOCIAL / PEERS
YesNo
NAME OF PERSON:
YESNO
WHY?
WHO DO YOU SPEND MOST OF YOUR TIME WITH? WHAT DO YOU DO FOR FUN?
DESCRIBE YOUR RELATIONSHIP WITH YOUR CURRENT SPOUSE OR ROMANTIC COMPANION. INCLUDE ANY HISTORY OF VIOLENCE OR CRIMINAL BEHAVIORS. IS HE/SHE A GOOD INFLUENCE IN YOUR LIFE?
DESCRIBE YOUR RELATIONSHIP WITH YOUR OTHER FAMILY MEMBERS. ARE THEY AWARE OF YOUR OFFENSE?

XI. MARRIAGE / RELATIONSHIP / CHILDREN
SINGLEMARRIEDDIVORCEDWIDOWEDLIVING TOGETHER

Rows	CURRENT SPOUSE I ROMANTIC COMPANION	DATE AND PLACE OF MARRIAGE, OR WHEN RELATIONSHIP BEGAN	# OF CHILDREN
1

Rows	FORMER SPOUSE'S NAME (IF APPLICABLE)	DATE MARRIED	DATE DIVORCED	# OF CHILDREN
1
2
3

Rows	CHILDREN BORN TO YOU:	SEX	AGE	LIVES WITH YOU?
1
2
3
4
5

Rows	STEP-CHILDREN / ADOPTED CHILDREN	SEX	AGE	LIVES WITH YOU?
1
2
3
4

YESNO
WHEN?
WHO WAS YOUR CASEWORKER?
EXPLAIN:

XIII. SUBSTANCE ABUSE - TREATMENT
CHECK HERE IF YOU HAVE NEVER BEEN IN TREATMENT

YESNO
WHERE/FOR WHAT:
YESNO
WHEN/WHERE:
YESNO
WHY OR WHY NOT?
HOW HAS YOUR USE OF DRUGS / ALCOHOL IMPACTED YOUR RELATIONSHIPS WITH FAMILY MEMBERS, FRIENDS, AND/OR CO-WORKERS?

XVI. YOUR VIEWPOINT
CHECK HERE IF YOUR ATTORNEY ADVISED YOU NOT TO ANSWER THE FOLLOWING QUESTION.
HOW DO YOU FEEL ABOUT THIS CASE? DO YOU THINK YOU WERE TREATED FAIRLY?
CHECK HERE IF YOUR ATTORNEY ADVISED YOU NOT TO ANSWER THE FOLLOWING QUESTION.
WHAT INFLUENCED YOU TO COMMIT THIS OFFENSE?
YOUR OPINION
WHAT DO YOU THINK YOUR PUNISHMENT SHOULD BE?
HOW DO YOU FEEL ABOUT AUTHORITY FIGURES SUCH AS POLICE OFFICERS, PROBATION/PAROLE OFFICERS, AND JUDGES?
WHAT IS YOUR OPINION OF PROBATION?
WHAT WOULD YOU LIKE TO ACCOMPLISH IF PLACED ON PROBATION?

XVIII. DEFENDANT'S STATEMENT
IN ORDER TO GIVE THE JUDGE A CLEAR PICTURE OF WHY YOU ARE IN COURT NOW AND WHAT SENTENCE YOU SHOULD RECEIVE, IT IS IMPORTANT YOU TELL YOUR SIDE OF THE STORY: WHAT WAS YOUR INVOLVEMENT IN THE CRIME(S), ANY ERRORS MADE IN THE POLICE REPORTS, WHAT THE JUDGE MIGHT EXPECT YOUR BEHAVIOR TO BE AFTER SENTENCING, ETC.
CHECK HERE IF YOU DO NOT WISH TO WRITE A STATEMENT.CHECK HERE IF YOUR ATTORNEY ADVISED YOU NOT TO MAKE A STATEMENT.
STATEMENT: OR ANY ADDITIONAL INFORMATION YOU WOULD LIKE THE COURT TO CONSIDER:
YESNO
IF "YES", WHO AND WHY:
DEFENDANT'S SIGNATURE*

Clear
DATE

MonthDayYear
Date

IMPORTANT THINGS TO CONSIDER
WHILE ON PROBATION, YOU WILL BE SUBJECT TO THE FOLLOWING:
DRUG TESTING - THIS IS A STANDARD TERM OF PROBATION. THE FREQUENCY OF DRUG TESTING IS UP TO YOUR PROBATION OFFICER. YOU WILL BE RESPONSIBLE FOR THE COST OF THE DRUG TESTING, TYPICALLY BETWEEN $5 TO $15 PER TEST.
ALCOHOL RESTRICTIONS - IF THE JUDGE ORDERS NO ALCOHOL, YOU WILL NOT BE PERMITTED TO CONSUME ALCOHOL. FURTHER, YOU MAY NOT HAVE ANY ALCOHOL IN YOUR RESIDENCE. ANY ALCOHOL FOUND WILL BE CONSIDERED YOURS AND YOU MAY BE SUBJECT TO A PROBATION VIOLATION.
TREATMENT - THE JUDGE OR YOUR PROBATION OFFICER MAY DIRECT YOU TO PARTICIPATE IN A TREATMENT PROGRAM. THIS WILL BE AT YOUR OWN EXPENSE, ALTHOUGH HEALTH INSURANCE (INCLUDING AHCCCS) CAN REDUCE THE COST SIGNIFICANTLY.
CONTACT RESTRICTIONS - YOU WILL NOT BE ALLOWED TO ASSOCIATE WITH ANYONE WITH A CRIMINAL RECORD (I.E. CONVICTED FELONS, OTHERS ON PROBATION/PAROLE, CO-DEFENDANTS) WITHOUT YOUR PROBATION OFFICER'S APPROVAL. THIS MAY INCLUDE FAMILY MEMBERS. YOUR PROBATION OFFICER WILL DETERMINE IF CONTACT WILL BE ALLOWED OR NOT.
WEAPONS RESTRICTIONS - WHILE ON PROBATION YOU ARE PROHIBITED FROM POSSESSING FIREARMS, DEADLY WEAPONS, AMMUNITION, STUN GUNS, AND TASERS. EVEN IF THEY DO NOT BELONG TO YOU, THESE ITEMS MAY NOT BE AT YOUR RESIDENCE OR ANYWHERE THAT YOU HAVE ACCESS TO THEM. YOUR PROBATION OFFICER WILL DECIDE IF WEAPONS NOT BELONGING TO YOU CAN REMAIN THERE IF PROPERLY SECURED.
RESIDENCE CHANGES - YOU MAY ONLY CHANGE YOUR ADDRESS WITH YOUR PROBATION OFFICER'S PERMISSION AHEAD OF TIME. IF YOU MOVE AND DO NOT TELL YOUR PROBATION OFFICER, IT IS LIKELY A WARRANT WILL BE ISSUED FOR YOUR ARREST AND YOUR PROBATION MAY BE REVOKED.
TRANSPORTATION - YOU ARE RESPONSIBLE FOR TRANSPORTATION TO OFFICE MEETINGS WITH YOUR PROBATION OFFICER, AS WELL AS TO TREATMENT, DRUG TESTING, COMMUNITY SERVICE, COURT DATES, ETC.
SEARCH AND SEIZURE - WHILE ON PROBATION YOU WILL NOT BE AFFORDED FULL PROTECTION UNDER THE 4^TH AMENDMENT TO THE U.S. CONSTITUTION. PROBATION OFFICERS HAVE THE RIGHT TO SEARCH AND SEIZURE WITHOUT A SEARCH WARRANT. THIS MEANS PROBATION OFFICERS CAN ENTER YOUR RESIDENCE AT ANY TIME EVEN IF YOU ARE NOT AT HOME. PROBATION OFFICERS HAVE AUTHORITY UNDER STATE LAW TO DETAIN EVERYONE IN YOUR HOME FOR THEIR SAFETY WHILE AT YOUR RESIDENCE. EVEN IF YOU DO NOT PERSONALLY OWN THE RESIDENCE WHERE YOU LIVE, IF YOU ARE THERE, IT IS CONSIDERED TO BE YOUR RESIDENCE. ESSENTIALLY, ANYTHING THAT YOU HAVE ACCESS TO, YOUR PROBATION OFFICER HAS ACCESS TO.
REMINDER: YOU MUST REPORT TO THE PROBATION OFFICER AT THE COURTHOUSE OR AT THE KINGMAN OFFICE OF THE PROBATION DEPARTMENT IMMEDIATELY FOLLOWING SENTENCING OR RELEASE.
LIVING IN ANOTHER ARIZONA COUNTY:
IF YOU PLAN ON LIVING IN A COUNTY OTHER THAN MOHAVE, YOU WILL BE SUBJECT TO WHAT IS CALLED "COURTESY SUPERVISION". PRIOR TO LEAVING MOHAVE COUNTY, YOU MUST MEET WITH YOUR PROBATION OFFICER, COMPLETE A COURTESY SUPERVISION APPLICATION, AND PAY A $150.00 APPLICATION FEE. THE OTHER COUNTY MAY WISH TO INVESTIGATE WHERE YOU PLAN TO LIVE, WORK, ETC PRIOR TO ACCEPTING YOU. IN SUCH CASES, YOU WILL BE REQUIRED TO REMAIN IN MOHAVE COUNTY UNTIL ACCEPTANCE IS RECEIVED.
IF YOU ARE A RESIDENT OF THAT COUNTY AT SENTENCING (MEANING YOU HAVE LIVED THERE AT LEAST 180 DAYS AND CAN SHOW PROOF), YOU WILL BE PERMITTED TO RETURN HOME THE DAY OF SENTENCING, BUT YOU MUST STILL MEET WITH A PROBATION OFFICER HERE, COMPLETE THE APPLICATION, AND PAY THE APPLICATION FEE BEFORE LEAVING. THIS CAN USUALLY BE ACCOMPLISHED BY MEETING WITH THE PROBATION OFFICER AT THE SUPERIOR COURTHOUSE, OR YOU MAY REPORT TO THE KINGMAN OFFICE OF THE PROBATION DEPARTMENT AT 809 E. BEALE STREET.
LIVING IN ANOTHER STATE WHILE ON PROBATION:
**IF YOU PLAN ON LIVING IN ANOTHER STATE BESIDES ARIZONA AFTER BEING PLACED ON PROBATION, PLEASE READ BELOW **
REQUIRED INTERSTATE COMPACT APPLICATION AND EXTRADITION BOND FEES
Alaska/Hawaii and all US Territories will be assessed at $3000
ALL PROBATIONERS PLANNING TO RESIDE IN ANOTHER STATE SHALL PAY THE
$300.00 APPLICATION FEE AND THE FULL AMOUNT OF THE EXTRADITION BOND
(SEE MAP) PRIOR TO REQUESTING TO TRANSFER SUPERVISION UNDER THE
INTERSTATE COMPACT FOR ADULT OFFENDER SUPERVISION.
YOU MUST SEE THE PROBATION OFFICER IN THE COURTHOUSE FOLLOWING
SENTENCING IF YOU PLAN TO LIVE IN ANOTHER STATE – PLAN TO STAY IN
ARIZONA AT LEAST ONE DAY, IN CASE THE PROBATION OFFICER IN THE
COURTHOUSE CANNOT MEET WITH YOU IMMEDIATELY.
Should be Empty:

Rows	YES	NO
1. Did you use larger amounts of drugs or use them for a longer time than you planned or intended?
2. Did you try to control or cut down on your drug use but were unable to do it?
3. Did you spend a lot of time getting drugs, using them, or recovering from their use?
4. Did you have a strong desire or urge to use drugs?
5. Did you get so high or sick from using drugs that it kept you from working, going to school, or caring for children?
6. Did you continue using drugs even when it led to social or interpersonal problems?
7. Did you spend less time at work, school, or with friends because of your drug use?
8. Did you use drugs that put you or others in physical danger?
9. Did you continue using drugs even when it was causing you physical or psychological problems?
10a. Did you need to increase the amount of a drug you were taking so that you could get the same effects as before?
10b. Did using the same amount of a drug lead to it having less of an effect as it did before?
11a. Did you get sick or have withdrawal symptoms when you quit or missed taking a drug?
11b. Did you ever keep taking a drug to relieve or avoid getting sick or having withdrawal symptoms?

Rows	Never	Only a Few Times	1-3 Times per month	1-5 Time per week	Daily
Alcohol
Cannaboids - Marijuana (weed)
Cannaboids – Hashish (hash)
Synthetic Marijuana (K2/Spice)
Natural Opioids – Heroin (smack)
Synthetic Opioids – Fentanyl/Iso)
Stimulants – Powder cocaine (coke)
Stimulants – Crack Cocaine (rock)
Stimulants – Amphetamines (speed)
Stimulants – Methamphetamine (meth)
Synthetic Cathinones (Bath Salts)
Club Drugs – MDMA/GHB/Rohypnol (Ecstasy
Dissociative Drugs – Ketamine/PCP (Special K)
Hallucinogens – LSD/Mushrooms (acid)
Inhalants – Solvents (paint thinner)
Prescription Medications – Depressants
Prescription Medications – Stimulants
Prescription Medications – Opioid Pain Relievers
Other

MOHAVE COUNTY ADULT PROBATION DEPARTMENT

PRE-SENTENCE INVESTIGATION QUESTIONNAIRE

PURPOSE OF THE PRE-SENTENCE INVESTIGATION REPORT (PSI):

Instructions for returning this questionnaire:

I. PERSONAL INFORMATION

II. PHYSICAL HEALTH

III. MENTAL HEALTH

IV. RESIDENCE / NEIGHBORHOOD

V. EMPLOYMENT / VOCATIONAL

VI. FINANCIAL

VII. EDUCATION

VIII. MILITARY SERVICE:

IX. FAMILY HISTORY:

X. SOCIAL / PEERS

XI. MARRIAGE / RELATIONSHIP / CHILDREN

XII. SUBSTANCE ABUSE - HISTORY (TCU 5)

XIII. SUBSTANCE ABUSE - TREATMENT

XIV. CRIMINAL RECORD

AS AN ADULT, HOW MANY TIMES HAVE YOU BEEN:

XV. OTHER INFORMATION

XVI. YOUR VIEWPOINT

YOUR OPINION

XVIII. DEFENDANT'S STATEMENT

IMPORTANT THINGS TO CONSIDER

WHILE ON PROBATION, YOU WILL BE SUBJECT TO THE FOLLOWING:

LIVING IN ANOTHER ARIZONA COUNTY:

LIVING IN ANOTHER STATE WHILE ON PROBATION:

Rows	PROGRAM	DATE	INPATIENT / OUTPATIENT	COMPLETED?
1
2
3