HOW DID YOU FIND US?
WEB
FRIEND
SOCIAL MEDIA
OTHER
WHO REFERRED YOU?
FULL LEGAL NAME
*
ALSO KNOWN AS
ADDRESS
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
EMAIL
*
INSTAGRAM?
*
YES
NO
INSTAGRAM HANDLE
PHONE
PRIMARY
(###)
###
####
EMERGENCY CONTACT NAME
First Name
Last Name
EMERGENCY CONTACT #
OTHER
(###)
###
####
DATE OF BIRTH
MM
DD
YYYY
AGE
PLACE OF BIRTH
SOCIAL SECURITY #
EDUCATION LEVEL
Less than high school
High school diploma or equivalent
Some college, no degree
Postsecondary non-degree award
Associate’s degree
Bachelor’s degree
Master’s degree
Doctoral or professional degree
MILITARY SERVICE
Yes
No
MARITAL STATUS
Single
Married
Divorced or Separated
Widowed
EMPLOYER
EMPLOYER NAME
EMPLOYER PHONE
EMPLOYER ADDRESS
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
DURATION OF EMPLOYMENT
RESPONSIBILITIES AT WORK
IDENTIFY ANY MEDICAL DIAGNOSIS, ILLNESS, SURGERY OR DISABILITIES
ANY DRUG OR ALCOHOL DEPENDENCY ISSUES?
Yes
No
IF SO, HAVE YOU EVER SOUGHT TREATMENT
Yes
No
Does not apply
PSYCHOLOGICAL AND MENTAL HEALTH HISTORY
Have you ever been treated by a psychologist or mental health professional? If so, please give details including diagnosis, treatment, medications, etc.
WERE YOU ON PAROLE OR PROBATION AT THE TIME OF THE ALLEGED OFFENSE?
Yes
No
IF YES, WHAT WAS THE OFFENSE, LENGTH OF PROBATION, AND LENGTH OF SUSPENDED SENTENCE
PRIOR CRIMINAL RECORD
Please provide a brief summary of any prior criminal history
DATE OF ARREST
MM
DD
YYYY
TIME OF ARREST
Hour
Minute
Second
AM
PM
PLACE OF ARREST
IF YOU MADE A VERBAL OR WRITTEN STATEMENT TO THE POLICE, DESCRIBE THE STATEMENT AND WHETHER YOUR MIRANDA RIGHTS WERE VERBALLY OR OTHERWISE GIVEN
WITNESS NAME
First Name
Last Name
WITNESS PHONE
WITNESS ADDRESS
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
WITNESS NAME
First Name
Last Name
WITNESS PHONE
(###)
###
####
WITNESS ADDRESS
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
