PRETRIAL INTERVIEW WORKSHEET - PDF

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PRETRIAL INTERVIEW WORKSHEET - PDF Powered By Docstoc
					                                                                                         Revised 07/22/09
                            PRETRIAL INTERVIEW WORKSHEET


Date: ________________________________

Name: _____________________________________ Maiden Name: ________________________
      Last         First       Middle

Address: ________________________________________________________________________

Telephone: _____________________________Work #: _________________________

Age: ____________ Date of Birth: _________________Race:_______Sex:_________

Social Security Number: _____________________________

Birthplace: ______________________________County of Residence: _________________

Are you a citizen of the United States? __________If no, what is your Citizenship?
__________________________________________________________________________________

Weight: __________ Height: ___________ Eye Color:________Hair Color: __________

Identification Marks (scars, tattoos, etc): _________________________________________________

Next of Kin: _______________________________________________________________________
              Name            Relationship  Address                  Telephone No.

Your attorney’s name and telephone #: __________________________________________________

Driver’s License #: _____________________________________State_______________

Expiration Date: ______________________________

Offense:
What offense (s) have you been charged with:_____________________________________________
__________________________________________________________________________________

Briefly describe the circumstances of your arrest, what led to the offense, what happened and what is
your part in it? (Please be reminded that an admission of guilt statement is necessary for admission
into this program and any statement that you provide may be used against you in prosecution.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________



                                                  1
What are your feelings about the offense and your part in it? What effect, if any, has it had on you? Is
there anything you would like to do as a result? ___________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Juvenile: Have you ever been arrested as a Juvenile (age 17 or under)? ______ If yes, please describe:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Adult: Have you ever been arrested as an adult? ______ If yes, please describe: _________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________



                                         SOCIAL HISTORY

Family

Father’s Name: ______________________________Age: _________Occupation:________________

Address: __________________________________________________________________________

Number of Marriages: ______________Arrest record: ________________________If so, for what?
__________________________________________________________________________________

Mother’s Name: _____________________________Age:_________ Occupation:________________

Address: __________________________________________________________________________

Number of Marriages: ______________Arrest record: ________________________If so, for what?
__________________________________________________________________________________




                                                   2
Stepmother’s name: ___________________________Age:________ Occupation: _______________

Stepfather’s name: ____________________________Age:________ Occupation: _______________

Legal Guardian: ______________________________Age:________ Occupation: _______________

Address: ______________________________________________Phone #_____________________

Number of Marriages: ______________Arrest record: ________________________If so, for what?
__________________________________________________________________________________

Quality of relationship (how well do you get along)? _______________________________________

Siblings: Please list all brothers and sisters
Name                                 Age             Address                      Arrest record

1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
4. ________________________________________________________________________________
5. ________________________________________________________________________________
6. ________________________________________________________________________________
7. ________________________________________________________________________________
8. ________________________________________________________________________________
9. ________________________________________________________________________________

Please list schools attended:
Grades        Dates           School           City/State              Major                   .




__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Overall High School grade average: _______________________College average:________________

Extracurricular activities in school (s) ___________________________________________________
__________________________________________________________________________________

Have you had any vocational training?_______________If so, what and in what area? _____________




                                                 3
What are your activities in your spare time? ______________________________________________
__________________________________________________________________________________

Do you smoke? (what, how much)______________________________________________________
Do you drink? (what, how much)_______________________________________________________

Have you ever had any alcohol or drug counseling? ________If so, where and when? _____________
__________________________________________________________________________________

Have you ever used any form of drugs? _______ If so, what kind and when? ____________________
__________________________________________________________________________________

__________________________________________________________________________________

Are you currently using any drugs?____________________If so, what kind? ____________________

__________________________________________________________________________________


                                         EMPLOYMENT

Beginning with current employer, please list the following:

Dates       Name/Address/Phone           Supervisor       Position   Salary   Reason for Leaving
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
What are your career goals, if any? _____________________________________________________
__________________________________________________________________________________

If you are not currently working, who supports you? _______________________________________

What is your gross monthly income from employment? _____________________________________

Do you have income from any other sources? ____________ If so, what and how much? __________
__________________________________________________________________________________
__________________________________________________________________________________


                                                 4
MONTHLY EXPENSES

Mortgage/Rent: ______________ Per Month ____________ Total owed: ___________________

Car Payment: _______________ Per Month ____________ Total owed: ___________________

Medical Bills: _______________ Per Month ____________ Total owed: ___________________

Utilities: ____________________Per Month ____________ Total owed: ___________________

Credit cards: ________________ Per Month ____________ Total owed: ___________________

Other: _____________________ Per Month ____________ Total owed: ___________________


                                   PERSONAL REFERENCES

Please list personal character referenced who are aware of the charges pending against you:
Name                              Address                                          Phone Number

1.______________________________________________________________________________
2.______________________________________________________________________________
3.______________________________________________________________________________
4.______________________________________________________________________________
5.______________________________________________________________________________


                                       MARITAL HISTORY

Number of marriages: ____________________ For each marriage, please list the following:

Name of spouse: ____________________________ Age: ____ Occupation: ____________________
Date of marriage: ______________________ Place of marriage: ______________________________
Date of divorce: _____________________ How is your current relationship with your current spouse?
__________________________________________________________________________________

Do you have any children? _________If so, please list as follows:

Name              DOB        Address             Mother’s Name                Father’s Name       .




__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

                                                  5
                                             MILITARY

Have you ever served in the military? ____________If so, please list branch, date: ________________
__________________________________________________________________________________

If you are not currently in the military, have you registered with selective services? _______________
__________________________________________________________________________________

                                     RESIDENTIAL HISTORY

Please list the following in reference to where you have lived:

AGE                                            CITY/STATE                                            .



__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you currently live in a house or an apartment? _________________________________________

How many bedrooms and bathrooms? ___________________________________________________

Names of persons currently living with you: ______________________________________________

What is the condition of your residence? _________________________________________________

                                               HEALTH

Are you currently in good physical health? ____________If no, explain: ________________________
__________________________________________________________________________________

Have you ever had any serious illnesses or accidents? _______If yes, explain: ___________________
__________________________________________________________________________________

Do you have any handicaps or deformities? _________If yes, explain: _________________________
__________________________________________________________________________________

Have you or any of your family members ever been treated by a Psychologist or Psychiatrist? _______
If yes, explain: ______________________________________________________________________
__________________________________________________________________________________
If accepted to this program, what are your plans regarding residence, employment, education?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

                                                   6
If restitution is due in this case, are you willing to make the necessary payments? _________________

In addition to supervision, one of the purposes of the pretrial intervention program is to assist the
participant in areas of need (emotional, psychological, employment, vocational, educational, etc.). If
you are accepted into this program, what do you feel are your needs and in which areas would you
need assistance? ____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

If you do not currently have your high school diploma or stable employment, you may be required to
attend school or some sort of vocational training. Are you willing to do this voluntarily? __________

Some participants in this program are required to contribute 40 (forty) hours of their time to the
community in the form of volunteer work. Are you willing to do this voluntarily? ________________

If you are accepted into this program and your pretrial intervention supervisor feels that you are in
need of some sort of counseling, are you willing to submit to this voluntarily? ___________________


I hereby certify that the above information is true and correct to the best of my knowledge and belief.


_______________________________________                _________________________
Signature                                               Date




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                                                   7
                                            FINANCIAL AFFIDAVIT

State of Florida, County of Broward
Before me, the undersigned authority, personally appeared __________________________________,
who was sworn and says that the following statement of affiant’s employment, income, expenses,
assets and liabilities is true:

Occupation: _______________________________________________________________________

Employed by: ______________________________________________________________________

Address: __________________________________________________________________________

Pay period:          Weekly                Bi-weekly                  Monthly           (circle one)

Rate of pay: ________ per hour             or    __________ salary $______________________
---------------------------------------------------------------------------------------------------------------------------
ITEM 1: INCOME (Averaged on a Monthly Basis)

Average gross wage per month:                                           $_______________________
Less deductions: Federal Income Tax $_______________
                 Social Security    $_______________
                 Other              $_______________
Total deductions:                                   $_______________________
Average net wage:                                   $_______________________
Itemize other income: _____________________________
_______________________________________________

TOTAL NET INCOME:                                                       $_______________________
---------------------------------------------------------------------------------------------------------------------------
ITEM 2: EXPENSES (Averaged on a Monthly Basis)
Rent, house payments:                                                   $_______________________
Food:                                                                   $_______________________
Clothing:                                                               $_______________________
Incidentals:                                                            $_______________________
Medical and dental:                                                     $_______________________
Transportation:                                                         $_______________________
Insurance:                                                              $_______________________
Taxes-property:                                                         $_______________________
Light, gas, telephone:                                                  $_______________________
Average child support paid:                                             $_______________________
Other monthly bills:                                                    $_______________________
TOTAL EXPENSES:                                                         $_______________________
---------------------------------------------------------------------------------------------------------------------------
                                                      SUMMARY
Net income:                                                             $_______________________
Less expenses:                                                          $_______________________

---------------------------------------------------------------------------------------------------------------------------
                                                             8
ITEM 3: ASSETS

Cash on hand or in banks:                             $_______________________
Stocks, bonds, notes:                                 $_______________________
Real estate: Home                                     $_______________________
               Other                                  $_______________________
Automobiles: Make _________ Model ________Year____ $_______________________
Other personal property:                              $_______________________
Itemize other assets: _______________________________
________________________________________________ $_______________________
TOTAL ASSESTS:                                        $_______________________

------------------------------------------------------------------------------------------------------------

ITEM 4: LIABILITIES

Credit union:                                         $_______________________
Real estate mortgages:                                $_______________________
Automobile loans:                                     $_______________________
Other notes or loans: _______________________________
________________________________________________ $_______________________

TOTAL LIABILITIES:                                                      $_______________________


____________________________________                             ______________________________
Affiant’s signature                                              (Print Affiant’s name)


Sworn to and subscribed on this _______day of __________, 2009


_______________________________________
Notary Public


_______________________________________
My commission expires




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