Community Sentencing Program

Community Sentencing Program

INTAKE FORM

PLEASE PRINT CLEARLYDOC# ______

Date: ______LSI SCORE ______

Name: ______Case Number: ______

LASTFIRSTMIDDLE

Charge (s): ______Judge: ______

Sentence: ______Date of Sentence: ______

Gender: MF Date of Birth: ______Place of Birth: ______

(City/Town and State)

Height: ______Weight: ______Hair: ______Eyes: ______Complexion: ______

(fair, medium, dark)

Build: ______Race: ______Scars, Marks and Tattoos: ______

Social Security Number: ______

Present Address: ______

(Street address, include apartment number)(City/State)(Zip code)

Mailing Address: ______

(if different)(Street Address, include apartment number)(City/State)(Zip code)

How long at current address? ______Marital Status? ______

If married, Date of Marriage: ______Place: ______If divorced, Date of: ______

(City, County, State)(Mm/dd/yy)

Phone Number(s): ______/ ______/ ______

(Home)(Cell) (Work)

Directions to Residence (rural areas): ______

______

Education

Name of Last School Attended: ______Highest Grade Completed: ______

(Name of School, City, State)

Date Last Attended: ______Year Graduated High School: ______

(Month/ Year)

Name of Last College Attended: ______Number of Hours Completed: ______

(Name of School, City, State)

Degree(s) Obtained: ______Other Education or Training Obtained: ______

______

PERSONAL and PROFESSIONAL CONTACTS (NON FAMILY)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Family Information

Father, mother, sister, brother, spouse, children are required.

Additional family members may be listed.

Name: ______Relationship: ______Age: ____

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

Name: ______Relationship: ______

LASTFIRSTMIDDLE

Address: ______

(Street Address, include apartment number) (City/ State) (Zip Code)

Occupation: ______Employer: ______

Phone Number(s): ______/ ______/ ______

(Home)(Work)(Cell)

CURRENT EMPLOYMENT

Are you currently employed?YESNOIf no, indicate reason: ______

______

Name of Employer: ______

Address: ______

(Street Address) (City/State) (Zip Code)

Phone Number: ______Occupation: ______

Date Started: ______Work hours: From______To______Work Days: ______

Salary: ______per WEEK or MONTH

Is your employer aware you are under supervision? YES or NO Can your Probation Officer contact your employer? YES or NO

Prior Employment

Name of Employer: ______

Address: ______

(Street Address) (City/State) (Zip Code)

Phone Number: ______Occupation: ______

Date Started: ______Work hours: From______To______Work Days: ______

Salary: ______per WEEK or MONTH

Name of Employer: ______

Address: ______

(Street Address) (City/State) (Zip Code)

Phone Number: ______Occupation: ______

Date Started: ______Work hours: From______To______Work Days: ______

Salary: ______per WEEK or MONTH

Name of Employer: ______

Address: ______

(Street Address) (City/State) (Zip Code)

Phone Number: ______Occupation: ______

Date Started: ______Work hours: From______To______Work Days: ______

Salary: ______per WEEK or MONTH

Financial Information

Income Amount: ______Source: ______

Expense Amount: ______Payment For: ______

Military Record

Enlistment Date: ______Branch: ______Enlistment Location: ______

Unit Number: ______Service Number: ______

Discharge Date: ______Discharge Location: ______Type of Discharge: ______

(Post Assignment, City, State)

Rank at Discharge: ______

HEALTH

Indicate any past or present, physical or mental, health problems.

Problem: ______

Onset Date: ______Inactive Date: ______if applicable.

Treatment Received: ______

Treatment Provider: ______

Problem: ______

Onset Date: ______Inactive Date: ______if applicable.

Treatment Received: ______

Treatment Provider: ______

List all medication you are legally taking:

______

Substance Abuse History

Type of Substance: ______Age of First Use: ______

Age of First Use: ______Period of Use (how long): ______How Often: ______

Treatment Attended: ______Length of Treatment? ______

Treatment Provider: ______

Location of Provider: ______

(Address, City, State)

Type of Substance: ______Age of First Use: ______

Age of First Use: ______Period of Use (how long): ______How Often: ______

Treatment Attended: ______Length of Treatment? ______

Treatment Provider: ______

Location of Provider: ______

(Address, City, State)

Type of Substance: ______Age of First Use: ______

Age of First Use: ______Period of Use (how long): ______How Often: ______

Treatment Attended: ______Length of Treatment? ______

Treatment Provider: ______

Location of Provider: ______

(Address, City, State)

Type of Substance: ______Age of First Use: ______

Age of First Use: ______Period of Use (how long): ______How Often: ______

Treatment Attended: ______Length of Treatment? ______

Treatment Provider: ______

Location of Provider: ______

(Address, City, State)

Comments

______

Revised 10/04