Juvenile Probation Intake Form
Full Legal Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Age
*
Your Email
example@example.com
Parent's Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Who do you live with?
*
Relationship
*
Mother's Full Name
First Name
Last Name
Mother's date of birth
-
Month
-
Day
Year
Date
Is she living?
Yes
No
Mother's address if different than yours
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's employer
Mother's work phone
Please enter a valid phone number.
Father's full name
First Name
Last Name
Father's date of birth
-
Month
-
Day
Year
Date
Is he living?
Yes
No
Father's address if different than yours
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's employer
Father's work phone
Please enter a valid phone number.
Are your parents
*
married
single
divorced
not married
re-married
Are your parents residing together?
*
Yes
No
If not, do they share custody?
Yes
No
Are either of your parents incarcerated at this time?
*
Yes (Mother)
Yes (Father)
Yes (Mother and Father)
No
If yes, where are they incarcerated?
e.g. "Mother(Jail), Father(Jail)
Name of School
*
Current Grade:
*
Middle School Grade 6
Middle School Grade 7
High School Grade 8
High School Grade 9
High School Grade 10
High School Grade 11
High School Grade 12
Counselor Name
*
Do you have an IEP or 504?
Are you currently expelled?
*
Yes
No
Have you ever been expelled in the past?
*
Yes
No
If yes, please provide dates and reason for expulsion
Dates
Reason
1
2
3
4
5
Employer
Employer Phone Number
Please enter a valid phone number.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hours per week
Are you currently or have you ever been in therapy, counseling or court ordered treatment?
*
Yes
No
If yes, what for?
Name of Therapist
Phone of Therapist
Please enter a valid phone number.
Have you or your family ever had involvement with Social Services?
*
Yes
No
If yes, when and for what reason?
When
Reason
1
2
3
4
5
Are you taking any medication?
*
Yes
No
If yes, what are you taking and what is the reason?
Medication
Reason
1
2
3
4
5
Do you have any charges pending in this or any other court?
*
Yes
No
If yes, please provide the charge and jurisdiction
Charge
Jurisdiction
1
2
3
4
5
Are you on probation/parole/diversion in any other jurisdiction?
*
Yes
No
If yes, please provide the charge and jurisdiction
Charge
Jurisdiction
1
2
3
4
5
Name of probation/parole officer?
Probation officer phone number
Please enter a valid phone number.
Criminal History, including any juvenile offenses, arrests, deferred judgments, and dismissals.
Charge
Jurisdiction
Date
1
2
3
4
5
Today's Date
*
-
Month
-
Day
Year
Signature
*
Submit
Should be Empty: