Skip to Main Content
Loading
Loading
Community Alert
COVID-19 VACCINE
Read on Leer on
About Us
Departments
Community
Online Services
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Court Services Forms
Waseca County
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
PSI Questionnaire
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Step One
This section is complete
This section is incomplete
2.
Step Two
This section is complete
This section is incomplete
3.
Step Three
This section is complete
This section is incomplete
4.
Step Four
This section is complete
This section is incomplete
5.
Step Five
This section is complete
This section is incomplete
6.
Step Six
This section is complete
This section is incomplete
7.
Step Seven
This section is complete
This section is incomplete
8.
Step Eight
This section is complete
This section is incomplete
9.
Step Nine
This section is complete
This section is incomplete
10.
Step Ten
This section is complete
This section is incomplete
Step One
First Name
Last Name
Date of Birth:
City/State you were born?
Alias/Maiden/Nickname(s):
Height
Weight
Race
Hair Color
Eye Color
Social Security Number
Describe any marks, scars, or tattoos you have:
Are you a United States citizen?
Yes
No
If no, what country?
What is your primary language?
Other language(s):
Address1
Address2
City
State
Zip
How long have you lived at your current address?
Who do you currently live with?
Address1
Mailing address (if different)
Address2
City
State
Zip
If you have been at current address less than three (3) years, where else have you lived? (list all addresses below)
List all other Cities/States for which you've resided in your lifetime:
Phone number(s):
Email address:
Did you serve any jail time as a result of the arrest within this Court Case?
Yes
No
If yes, how many days did you serve?
Did you post any Bail in this Case?
Yes
No
What other active conditions were you ordered to follow while your case was pending?
PRIOR RECORD
How old were you the first time you were in trouble with the law?
List your juvenile offenses:
How many adult convictions do you have?
As specific as possible, list all adult convictions in area below (include the year, offense, and city/state)
Have you ever been incarcerated for any crime?
Yes
No
If yes, for which offense(s)?
If incarcerated, have you ever been disciplined within the facility (verbal warning, sent to segregation, etc.)?
Yes
No
If yes, for what?
Have you ever been on probation?
Yes
No
Are you currently on probation?
Yes
No
If yes, provide the name of your last/current probation officer:
Do you have any other pending offenses?
Yes
No
If yes, please list those here:
Have you ever violated probation or conditions of release?
Yes
No
EMPLOYMENT/FINANCES
What is the current status of your employment? (check which applies)
Employed full-time
Employed part-time
Unemployed
If employed part-time, how many hours per week are you working? If unemployed, how long have you been unemployed?
Do you like your present employment?
Yes
No
What do you like best about your present employment?
How would you rate your performance within your recent employment?
How would you rate your performance within your recent employment?
What would your boss say about your performance?
Describe your relationship with your present boss?
Describe your relationship with your co-workers?
Do you spend time outside of work with your co-workers?
Yes
No
If yes, what activities do you share with them?
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
In the last 12 months, how many months were you employed full-time?
How many jobs have you held in the last 12 months?
Where was your longest term of employment?
How long?
Have you ever been fired from employment?
Yes
No
List any other sources of income (include Social Security, child support, disability, unemployment, income from spouse or significant other, etc.):
Income Source
Monthly amount received
Income Source
Monthly amount received
Income Source
Monthly amount received
List major monthly expenses paid per month (house payments, rent, credit card payments, car payments, cell phone bills, utilities, medical bills, etc.):
Expense
Monthly payment
Expense
Monthly payment
Expense
Monthly payment
Do you have any debts?
Yes
No
If yes, please list below:
Debt
Amount owed
Debt
Amount owed
Debt
Amount owed
Are you worried about having enough money to meet your needs?
Yes
No
In the past year, have you experienced any financial problems?
Yes
No
If yes, please describe:
Continue
Step Two
MILITARY
Did you participate in the United States Military?
Yes
No
If no, skip to the education section. If yes, complete the following:
Date of Enlistment:
Date of Discharge:
Branch of Military:
Last Rank:
Type of Discharge:
Special Training:
Have you ever received disciplinary actions (Article 15)?
Yes
No
Have you been involved with Veteran's Affairs?
Yes
No
Continue
|
Go Back
Step Three
EDUCATION
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?
If you did not graduate from high school, did you receive your GED?
Yes
No
If yes, what year?
Where?
List all schools that you attended, beginning with high school (include post-secondary schooling)
School Name
City/State
Year(s) Attended
Diploma/Degree
School Name
City/State
Year(s) Attended
Diploma/Degree
School Name
City/State
Year(s) Attended
Diploma/Degree
Did you receive any Special Education Services?
Yes
No
If yes, what service(s)?
Did you have any learning disabilities?
Yes
No
If yes, please explain:
Describe what kind of student you were (grades, activities, sports):
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)?
How would you describe your participation in school?
Describe your relationship with other students:
Describe your relationship with your teachers /principals?
Continue
|
Go Back
Step Four
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
Marital Status:
Single
Married
Divorced
Separated
Widowed
Significant Other (if any):
Age
How long have you been in this relationship?
Describe your relationship with your spouse or significant other:
How satisfied are you with your present relationship/marital situation?
How many times have you been married?
List all former spouse(s):
Do you have any children?
Yes
No
If yes, list them below:
Children's Names
Ages
Cities/States residing
Other Parent's Name
List if each child is biological or a step-child
Do you currently have any Order for Protection, No Contact Order, or Harassment/Restraining Order against you?
Yes
No
Is yes, by whom?
Have you ever had any Order for Protection, No Contact Order, or Harassment/Restraining Order against you?
Yes
No
If yes, by whom?
Your Father's Name
Age
Address1
Address2
City
State
Zip
Phone:
How often do you have contact with your father?
Describe your current relationship with your father:
Describe your relationship with your father when you were growing up:
Your mother's name
Age
Address1
Address2
City
State
Zip
Phone:
How often do you have contact with your Mother?
Describe your current relationship with your Mother:
Describe your relationship with your Mother when you were growing up:
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-parent(s):
Who was your primary caregiver(s) while growing up?
Did you ever live with anyone other than your parents during your childhood?
Yes
No
If yes, with whom?
Please describe your up-bringing in the space below:
List your Brothers and Sisters (including biological, step, half, and adopted siblings):
Name
Age
City & State of residence
Name
Age
City & State of residence
Name
Age
City & State of residence
Describe your relationship with your siblings:
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:
Has any of your family (Parents, Siblings, Spouse, Children, or any other close relative) ever been involved in the criminal justice system?
Yes
No
If yes, please list them:
In your leisure time, what activities do you enjoy?
Please provide names of three people (other than family members) who know you:
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
Continue
|
Go Back
Step Five
PHYSICAL HEALTH
How would you describe your health today?
-- Select One --
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 a 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:
Do you have health insurance?
Yes
No
If yes, name of provider:
List all medications that you are currently taking (prescribed and non-prescribed):
Continue
|
Go Back
Step Six
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
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 any 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 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
Has anyone ever told you to quit or cut back on drinking or using?
Yes
No
Please select 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 each chemical selected, indicate your age of first use, how often you use, how much you use per episode, and the date/age of last use:
What reasons do you use alcohol or drugs?
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
Check all that apply
Continue
|
Go Back
Step Seven
GAMBLING
Do you gamble (includes lottery tickets, casino games, pull tabs, raffles, etc.)
Yes
No
Have you ever thought or been told that you have a gambling problem?
Yes
No
Have you ever borrow money in order to gamble or cover lost money?
Yes
No
Have you ever felt the need to bet more and more money?
Yes
No
Have you been untruthful about the extent of your gambling or hid it from others?
Yes
No
Have you ever tried to stop or cut back on how much or how often you gamble?
Yes
No
Continue
|
Go Back
Step Eight
MENTAL HEALTH
For each of the following questions, please identify the last time that you had the problem, if ever, by selecting "in the past month" (3), "2-12 months ago" (2), "1 or more years ago" (1), or "Never" (0).
When was the last time you had significant problems with feeling very trapped, lonely, sad, blue, depressed or hopeless about the future?
-- Select One --
3
2
1
0
When was the last time you had significant problems with sleep trouble such as bad dreams, sleeping restlessly or falling asleep during the day?
-- Select One --
3
2
1
0
When was the last time you had significant problems with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?
-- Select One --
3
2
1
0
When was the last time you had significant problems with becoming very distressed and upset when something reminded you of the past?
-- Select One --
3
2
1
0
When was the last time you had significant problems with thinking about ending your life of committing suicide?
-- Select One --
3
2
1
0
When was the last time that you lied or conned to get things you wanted or to avoid having to do something, two of more times?
-- Select One --
3
2
1
0
When was the last time you had a hard time paying attention at school, work, or home, two or more times?
-- Select One --
3
2
1
0
When was the last time you had a hard time listening to instructions at school, work, or home, two or more times?
-- Select One --
3
2
1
0
When was the last time you were a bully or threatened other people, two or more times?
-- Select One --
3
2
1
0
When was the last time you started physical fights with other people, two or more times?
-- Select One --
3
2
1
0
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
Continue
|
Go Back
Step Nine
CURRENT OFFENSE
What is the first thing that comes to your 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 comment:
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:
Continue
|
Go Back
Step Ten
Please provide your version of this offense and the circumstances leading up to it.
Did you personally complete this entire questionnaire?
Yes
No
If no, please identify the person(s) that assisted you:
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
Submit and Print
|
Go Back
* indicates a required field
Home
Agendas & Minutes
Bids
Code Red
Employment Opportunities
Interactive County Map
Pay Property Tax
Salary Notification
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow
