Johnson County Juvenile Probation Preliminary Questionnaire
You must complete the information below prior to your scheduled appointment with your probation officer. Failure to do so may result in the delay or rescheduling of your appointment. If you do not know the answer to a question, you may leave it blank, however, you may be required to answer at a later date.
Youth Information
Youth Name:
*
Nickname:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary County of Residence:
*
Years Lived in Primary County:
*
Date of Birth:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City/State of Birth:
*
SSN:
*
Home Phone (if applicable):
Format: (000) 000-0000.
Youth Cell Phone:
Format: (000) 000-0000.
Gender:
*
Height:
*
Weight:
*
Hair Color:
*
Eye Color:
*
Race:
*
American Indian/Alaskan Native
Asian
Caucasian
Hispanic
Multi-Racial
Native Hawaiian/Pacific Islander
Punjub Indian
Unknown
Ethnicity:
*
Hispanic
Non-Hispanic
Citizenship Status:
*
U.S. Citizen
Non U.S. Citizen
Resident Alien
Does the youth have any scars?
*
Yes (If yes, explain below)
No
Use the below field to document any scars the youth has:
Does the youth have any birth marks?
*
Yes (If yes, explain below)
No
Use the below field to document any birthmarks the youth has:
Does the youth have any tattoos?
*
Yes (If yes, explain below)
No
Use the below field to document any tattoos the youth has:
Does the youth have a driver's license?
*
Yes
No
License Status:
Valid
Suspended/Pending Suspension
Issuing State:
Driver's License Number:
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Johnson County Juvenile ProbationPreliminary Questionnaire
Youth Additional Information
Has the youth been involved with Law Enforcement or Probation in any other county or state?
*
Yes
No
If yes, please list the below county and states in which the youth has had previous involvements with law enforcement and/or Probation.
Is the youth currently undergoing any medical treatment or counseling?
*
Yes
No
If yes, please provide information regarding the medical treatment and counseling the youth is receiving or has received in the past, including any mental health diagnosis:
Is the youth currently taking any medication?
*
Yes
No
If yes, please list all of the medications the youth is taking below:
Is your family currently involved with any other court system in or outside of Johnson County?
*
Yes
No
If yes, please list the court and locations below:
Is the youth currently involved or previously had involvement with the Indiana Department of Child Services?
*
Yes
No
If yes, please list the county and reason for the involvement below:
Is the youth adopted?
*
Yes
No
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age of Youth:
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Johnson County Juvenile ProbationPreliminary Questionnaire
Youth Education and Employment Information
Is your child currently enrolled in school?
*
Yes
No
Homeschool
Online/Virtual School
Current Grade:
School Name:
Is your child currently employed?
*
Yes
No
If your child is employed, please complete the information below.
Employer Name:
Hire Date:
Address:
City:
State:
Zip Code:
Phone Number:
Format: (000) 000-0000.
Supervisor/Manager Name:
Caregiver Information
Use the space below to provide information for the caregiver of the youth – including, if applicable, step parents.
Youth Caregiver 1 Information
Youth Legal Guardian 1 Name:
*
DOB:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Youth:
*
Biological Parent
Adoptive Parent
Step
Legal Guardian
Social Security Number:
*
Marital Status:
*
Married
Divorced
If married, what year?
If divorced, what year?
Race:
*
Caucasian
African-American
Asian
Indian
Hispanic
Mixed Race
Other:
Ethnicity:
*
Hispanic
Non-Hispanic
U.S. Citizenship Status:
*
U.S. Citizen
Resident Alien
None
Address:
*
Apartment Number:
City:
*
State:
*
Zip Code:
*
Home Phone:
Format: (000) 000-0000.
Cell Phone:
*
Format: (000) 000-0000.
Email Address (used for correspondence from the court):
*
example@example.com
Employer:
Shift Times/General Work Hours:
Criminal History:
*
None
Yes
If yes, use the space below to provide the name of the county and nature of the charges:
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Johnson County Juvenile Probation Preliminary Questionnaire
Custody Status:
*
Full Custody
Joint Custody
Youth Caregiver 2 Information:
Youth Legal Guardian 2 Name:
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Youth:
Biological Parent
Adoptive Parent
Step
Legal Guardian
Social Security Number:
Marital Status:
Married
Divorced
If married, what year?
If divorced, what year?
Race:
Caucasian
African-American
Asian
Indian
Hispanic
Mixed Race
Other:
Ethnicity:
Hispanic
Non-Hispanic
U.S. Citizenship Status:
U.S. Citizen
Resident Alien
None
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address (used for correspondence from the court):
example@example.com
Employer:
Shift Times/General Work Hours:
Criminal History:
None
Yes
If yes, use the space below to provide the name of the county and nature of the charges:
Custody Status:
Full Custody
Joint Custody
Youth Caregiver 3 Information
Youth Legal Guardian 3 Name:
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Youth:
Biological Parent
Adoptive Parent
Step
Legal Guardian
Social Security Number:
Marital Status:
Married
Divorced
If married, what year?
If divorced, what year?
Race:
Caucasian
African-American
Asian
Indian
Hispanic
Mixed Race
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Johnson County Juvenile Probation
Preliminary Questionnaire
Other:
Ethnicity:
Hispanic
Non-Hispanic
U.S. Citizenship Status:
U.S. Citizen
Resident Alien
None
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address (used for correspondence from the court):
example@example.com
Employer:
Shift Times/General Work Hours:
Criminal History:
None
Yes
If yes, use the space below to provide the name of the county and nature of the charges:
Custody Status:
Full Custody
Joint Custody
Youth Caregiver 4 Information
Youth Legal Guardian 4 Name:
DOB:
DOB
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Youth:
Biological Parent
Adoptive Parent
Step
Legal Guardian
Social Security Number:
Marital Status:
Married
Divorced
If married, what year?
If divorced, what year?
Race:
Caucasian
African-American
Asian
Indian
Hispanic
Mixed Race
Other:
Ethnicity:
Hispanic
Non-Hispanic
U.S. Citizenship Status:
U.S. Citizen
Resident Alien
None
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address (used for correspondence from the court):
example@example.com
Employer:
Shift Times/General Work Hours:
Criminal History:
None
Yes
If yes, use the space below to provide the name of the county and nature of the charges:
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Johnson County Juvenile ProbationPreliminary Questionnaire
Custody Status:
Full Custody
Joint Custody
Youth Siblings
Name:
Gender:
Male
Female
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Criminal History:
Yes
No
Resides with Youth:
Yes
No
Name:
Gender:
Male
Female
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Criminal History:
Yes
No
Resides with Youth:
Yes
No
Name:
Gender:
Male
Female
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Criminal History:
Yes
No
Resides with Youth:
Yes
No
Name:
Gender:
Male
Female
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Criminal History:
Yes
No
Resides with Youth:
Yes
No
Name:
Gender:
Male
Female
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Criminal History:
Yes
No
Resides with Youth:
Yes
No
Additional Information
Please select the Probation Officer that you received a letter from.
Please Select
Amy Heuchan
Brad Rynerson
Jasmine Copeman
Kate Ozembela
Libby Mudd
In the field below, please list any additional information that you believe would be helpful to ensure the success of your child:
Please verify that you are human
*
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