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Step One
PRE-DISPOSITIONAL INVESTIGATION QUESTIONNAIRE
Full Legal Name
Alias/Maiden/Nickname(s)
Date of Birth
City/State you were born
Height
Weight
Hair Color
Eye Color
Race
Are you a United States Citizen?
-- Select One --
Yes
No
If no, what country?
Describe any marks, scars, or tattoos you have.
What is your primary language?
Other Language(s)
Current Physical Address
How long have you lived at current address?
Mailing address, if different
Who do you currently live with?
List all other cities/states for which you've resided in your lifetime
Parent Phone Number
Juvenile Phone Number
Email Address
What other active conditions were you ordered to follow while your case was pending?
Continue
Step Two
PRIOR RECORD
How old were you the first time you were in trouble with the law?
List all offenses, arrests, whether adjudicated or not.
Include out of state information. List the offense, offense date, place, and disposition.
Were you ever placed outside of the home as a juvenile?
Yes
No
If yes, where?
Do you have any pending charges?
Yes
No
If yes, please describe:
Are you currently on probation?
Yes
No
If yes, provide the name of your last/current probation officer:
Have you ever been involved in a gang?
Yes
No
Have you ever violated probation or conditions of release?
Yes
No
Have you ever had your probation revoked?
Yes
No
Do you have any weapons in your home?
Yes
No
Have you ever been involved in fighting, assaultive behavior, or used any other forms of violence?
Yes
No
If yes, please explain:
Have you ever used a weapon against another person?
Yes
No
If yes, please explain:
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Step Three
EMPLOYMENT/FINANCES
What is the current status of your employment?
Employed full-time
Employed part-time
Unemployed
Do you like your present employment?
Yes
No
What do you like best about your present employment?
Describe your relationship with your present boss?
Describe your relationship with your co-workers?
Do your employers and co-workers know about the present offense?
Yes
No
If so, what do they think about it?
List your three most recent places of employment, giving the present/most recent first.
Employer
Location
Length
Wage
Reason for leaving
Employer
Location
Length
Wage
Reason for leaving
Employer
Location
Length
Wage
Reason for leaving
Have you ever been fired?
Yes
No
If yes, why?
Have your legal charged caused you to leave a job?
Yes
No
Have you ever walked off the job without giving notice?
Yes
No
Have you ever just quit going to a job?
Yes
No
List any other sources of income to the family (include Social Security, child support, disability, unemployment, etc):
List income source, monthly amount received, and if this amount has been received in the past year.
Do you have a savings or a checking account?
Yes
No
Do you have any credit cards?
Yes
No
Do you have any debts?
Yes
No
If yes, please list the debt and the amount owed.
In the past year, have you or your family experienced any financial problems?
Yes
No
If yes, please describe:
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Step Four
EDUCATION
What grade in school are you in?
Did you graduate from High School?
Yes
No
If yes, what year?
If you did not graduate from high school, what was the last grade you completed?
What year did you leave school?
Did you receive your GED?
Yes
No
If yes, what year and where?
List all schools that you attended (include post-secondary schooling)
School Name
City/State
Dates attended
Diploma/Degree
School Name
City/State
Dates attended
Diploma/Degree
School Name
City/State
Dates attended
Diploma/Degree
Did you ever repeat a grade?
Yes
No
If yes, which grade?
Do you receive any Special Education Services/IEP?
Yes
No
If yes, what service(s)?
Do you have any learning disabilities?
Yes
No
If yes, please explain:
Do you skip school? How often? What do you do?
Describe any problems you experienced in school:
Were you ever suspended from school?
Yes
No
Were you ever expelled from school?
Yes
No
If yes in one or both, for what reason(s)?
*
What school organizations or special activities did you participate in?
How well are you doing in your school work? What grades are you getting? Have you been doing better (or worse) recently?
Describe your relationship with other students:
Describe your relationship with your teachers/principals?
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Step Five
FAMILY AND FRIENDS
The following question is optional and will only be used to achieve more specific supervision of your case and cannot be used against you: Do you identify as:
Heterosexual
Homosexual
Bisexual
Significant Other (if any)
Age
How long have you been in this relationship?
How satisfied are you with your present relationship?
Describe your relationship with your significant other:
Do you have any children?
Yes
No
If yes, list them below:
Child's Name
Age
City and State residing
Other parent name
Child's Name
Age
City and State residing
Other parent name
Your father's name
Date of Birth
Birthplace
Address
Telephone Number
Employer
Position Held
How often do you have contact with your father?
Describe your relationship with your father?
Does he now or have he ever had psychological problems or drug/alcohol problems? Explain:
Your Mother's Name
Maiden Name
Birthplace
Date of Birth
Address
Telephone Number
Employer
Position Held
How often do you have contact with your mother?
Describe your relationship with your mother:
Does she now or has she ever had psychological problems or drug/alcohol problems? Explain:
Are your parents presently:
Married
Divorced
Separated
Never Married
Are you adopted?
Yes
No
Do you have step-parents?
Yes
No
If yes, list their names:
Describe your relationship with your step-parents:
Who is your primary caregiver(s)?
Have you ever lived with anyone other than your parents?
Yes
No
If yes, with whom?
Please describe your up-bringing in the space below:
What are the rules at home?
Do you think they are fair?
Yes
No
Do you think you should obey them?
Yes
No
What do your parents do when you break the rules? What are the consequences?
Do they follow through with the consequences?
Yes
No
List your brothers and sisters (including biological, step, half, and adopted siblings):
Include their name, age, and city and state of residence.
Describe your relationship with your siblings:
Have any of your siblings ever had psychological problems or drug/alcohol problems?
Yes
No
Have you ever been a victim of physical abuse?
Yes
No
If yes, please explain:
Have you ever been a victim of sexual abuse?
Yes
No
If yes, please explain:
Did you ever observe your parents abuse each other or other siblings?
Yes
No
If yes, please explain:
Have any of your family (parents, siblings, or any other close relative) ever been involved in the criminal justice system?
Yes
No
If yes, please list them:
What type of things do you do with your friends?
What do your friends say about your current offense?
Have any of your friends been in trouble with the law?
Yes
No
Have any of your friends NOT been in trouble with the law?
Yes
No
Have any of your acquaintances been in trouble with the law?
Yes
No
Have any of your acquaintances NOT been in trouble with the law?
Yes
No
Do your parents know what you are doing and whom you are with?
Yes
No
How do they feel about that/them?
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Step Six
PERSONAL INFORMATION
How would you describe yourself?
Would you describe yourself as a leader or a follower?
Do you consider yourself to be responsible and trustworthy?
Yes
No
What kinds of things make you especially angry?
How do you react when you are angry?
Are you easily frustrated or a fairly easygoing person?
Do you ever feel very anxious or depressed?
Yes
No
How often do you feel anxious or depressed?
Who do you talk to about your problems?
Are you good at planning things or do you tend to do things on the spur of the moment?
Do you feel you have a lot of control over your own decision making?
Yes
No
If not, why?
Do you have problems saying "no" to your friends when you disagree with them?
Yes
No
What are your strengths and personality traits you value about yourself?
What things do you feel you could improve about yourself?
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Step Seven
What do you like to do for fun?
Do you play video games at home?
Yes
No
If yes, what games do you play and how much time do you spend playing them?
Do you spend most of your leisure time with your family or friends?
Have you been active in any organizations or clubs during the past year (church, clubs, sports, etc)?
Yes
No
If yes, please describe:
Continue
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Step Eight
PHYSICAL HEALTH
How would you describe your health today?
Great
Good
Fair
Poor
Do you have any concerns about your health?
Yes
No
If yes, please explain:
List any major illnesses or surgeries you have had:
Have you had any serious falls or accidents resulting in head injury?
Yes
No
Do you have any disabilities or handicaps?
Yes
No
If yes, please describe:
Do you have any communicable disease(s)?
Yes
No
If yes, please list:
List all medications you are currently taking (prescribed and non-prescribed):
Continue
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Step Nine
ALCOHOL AND DRUG USE
Do you currently have a problem with alcohol?
Yes
No
Have you ever had a problem with alcohol?
Yes
No
Do you currently have a problem with drugs?
Yes
No
Have you ever had a problem with drugs?
Yes
No
Were you using or in possession of alcohol or drugs during this offense?
Yes
No
In the last year, has your use of alcohol or drugs contributed to law violations?
Yes
No
In the last year, has your family offered concern about your drinking/drug use?
Yes
No
Has anyone ever told you to quit or cut back on drinking or using?
Yes
No
Is there a history of chemical dependency in your immediate family (parents, grandparents, siblings)?
Yes
No
If yes, who?
Have you ever participated in chemical dependency treatment or education?
Yes
No
If yes, please list all:
Have you ever attended AA/NA/Alanon?
Yes
No
Have you ever experienced a blackout (inability to remember what happened during a period of time) after drinking alcohol?
Yes
No
Have you ever used chemicals to relieve a hangover?
Yes
No
Have you ever had problems in school or work because of your use of alcohol/drugs?
Yes
No
Is the amount of money you spend on alcohol or drugs a problem?
Yes
No
Have any of your relationships been damaged because of your chemical use?
Yes
No
Do you have health problems that are related to your chemical use?
Yes
No
Have you ever been admitted to detox due to chemical use?
Yes
No
Have you ever been hospitalized due to your chemical use?
Yes
No
Have you ever experienced withdrawl symptoms (shakes, hallucinations, etc) from use?
Yes
No
Have you ever experienced any medical problems due to drug or alcohol use? (i.e Hepatitis, sleep loss, memory loss, weight loss, dental, stomach, STD's, suicide attempts, injuries)
Yes
No
Have you ever been unable to stop drinking or using drugs when you wanted?
Yes
No
Please select all the chemicals you have used:
Alcohol
Marijuana
Cocaine/Crack
Meth/Amphetamines
Heroin
Other Opiates/Synthetics
Inhalants
Benzodiazepines
Hallucinogens
Barbituates/Sedative Hypnotics
Abuse of Over-the-counter medication
Nicotine
Other
For all the chemicals selected above, list the age of first use, how often you use, how much you use per time, and the date or age of last use.
What reasons do you use alcohol or drugs?
Select all that apply.
Like feeling high
Like feeling numb
Trying to forget problems
To cope with stress
To alleviate physical pain
Alleviates boredom
Everyone in social network uses
Partner encourages use
Can't function without it
To relax and unwind
To cope with an abusive partner
To cope with family problems
Afraid of withdrawl symptoms
Make it easier to talk with others
To cope with depression/anxiety
Continue
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Step Ten
MENTAL HEALTH
After each of the following questions, please identify the last time you had the problem, if ever.
When was the last time you had significant problems with:
Feeling very trapped, lonely, sad, blue, depressed or hopeless about the future?
Past month
2-12 Months ago
1+ years ago
Never
Sleep trouble such as bad dreams, sleeping restlessly or falling asleep during the day?
Past Month
2-12 Months ago
1+ years ago
Never
Feeling very anxious, nervous, tense, scared, panicked or like something bad was going to happen?
Past Month
2-12 Months ago
1+ years ago
Never
Becoming very distressed and upset when something reminded you of the past?
Past Month
2-12 Months ago
1+ years ago
Never
Thinking about ending your life by committing suicide?
Past Month
2-12 Months ago
1+ years ago
Never
When was the last time that you did the following things two or more times?
Lied or conned to get things you wanted or to avoid having to do something?
Past Month
2-12 Months ago
1+ years ago
Never
Had a hard time paying attention at school, work, or home?
Past Month
2-12 Months ago
1+ years ago
Never
Had a hard time listening to instructions at school, work, or home?
Past Month
2-12 Months ago
1+ years ago
Never
Were a bully or threatened other people?
Past Month
2-12 Months ago
1+ years ago
Never
Started physical fights with other people?
Past Month
2-12 Months ago
1+ years ago
Never
Have you ever been referred to a counselor/psychologist/psychiatrist/mental health unit?
Yes
No
If yes, please explain:
Have you ever been diagnosed or treated for a mental illness?
Yes
No
If yes, explain:
Have you ever inflicted injury upon yourself (cutting, burning, etc)?
Yes
No
Have you ever been suicidal or attempted suicide?
Yes
No
Do you currently feel depressed?
Yes
No
Do you take prescribed medications for mental health reasons?
Yes
No
If you are not taking medications, have you taken prescribed medications in the past?
Yes
No
Continue
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Step Eleven
CURRENT OFFENSE
What is the first thing that comes to mind when you think about the trouble you have been/are in?
In your opinion, what are the most significant reasons for being in trouble with the law?
What is your opinion of the law, police, and the Courts?
Is there ever a good reason to break the law?
Yes
No
If yes, please explain:
Do you feel your plea agreement was appropriate and fair?
Yes
No
Provide any related comments:
If you were the judge, what sentence would you give yourself?
How do you feel about being placed on probation as part of sentencing?
If you are currently under supervision, do you feel your probation officer is fair and reasonable?
Yes
No
Offer any related comment below:
Provide your verions of this offense and the circumstances leading up to it.
Name(s) of others involved:
Did you personally complete this entire questionnaire?
Yes
No
If no, please identify the person(s) that assisted you:
Attach any additional documents.
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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