Coles/Cumberland Court Services

Parent Interview Worksheet

PLEASE NOTE: Fill out this form in its entirety. DO NOT SKIP ANY PORTION. If a question does not apply to you, indicate why not. You should expect to spend one to two hours completing this form, and you will save yourself time by making sure that it is complete BEFORE bringing it in to review with a Probation Officer. This information is required for the development of the assessment and case planning for your child. Your information is confidential and is sealed to the public. Please use the back of the form, if needed. Thank you for your cooperation.

Minor’s Case Number: Date:

Last Name First Name Middle Name Maiden Name

Alias’ or Nicknames Age Date of Birth

Social Security # Place of Birth

U.S. Citizen Yes or No Legal Immigrant Yes or No Country

Race Sex Height Weight

Hair Eyes Tattoos or Scars

I. DESCRIPTIVE INFORMATION

Address Street City State Zip Living with whom______How Long?______(use back of page if necessary) Telephone Number(s) / / Home Work Emergency Previous Residences: 1. How Long With Whom

2. How Long With Whom

Have you ever resided in any other State? What State(s)

Driver’s License # State of Issue Is DL Suspended or Revoked? Why? Ever held DL in any other State? What State(s)? Vehicles Owned: Year Make Model Color Plate # State Registered To

Other Vehicles Driven:

Do you have Auto Insurance: With what company: Describe coverage:

Other means transportation:

Douglas County Probation, Parent Interview Worksheet, Page 1 II. PRIOR RECORD A. PRIOR JUVENILE RECORD

Were you ever arrested under the age of 16?______Were you taken to court as a Juvenile? County/State Were you found Delinquent Dependent/Neglected/Abused Minor in Need Were you ever a ward of any state? Did you ever serve a period of incarceration? County/State

B. PRIOR CRIMINAL ADULT RECORD:

Date Offense Outcome County/State Date Offense Outcome County/State Date Offense Outcome County/State

(Use back of page if necessary)

Do you have any charges pending? Are you currently on Conditional Discharge or Court Supervision? Are you on Parole/Mandatory Supervised Release? Are you on Probation in another Jurisdiction? Were you ever incarcerated upon conviction?______Do you have any history of escape and attempted escape from a youth or adult correctional facility, including residential facilities?______Were you ever punished for institutional misconduct?______

Do you carry, own, or have access to a firearm or any kind of weapon?______Have you ever purchased a weapon or had someone purchase one for you?______

III. CURRENT OFFENSE INFORMATION

Was your child under the influence of drugs/alcohol at the time of this offense: Did proceeds from the crime go toward purchase of alcohol and/or drugs: Were there co-defendants: Who: Describe relationship with co-defendants:

What is your version of what happened in this case:

______

IV. EDUCATION

Last High School attended Can you read: Write: Douglas County Probation, Parent Interview Worksheet, Page 2 Did you Graduate? If not, why? Highest Grade Completed

Have you completed the GED? When Where

College or Vocational Training Where When Field of Study Degree or Certificates Describe School Experiences (attendance, discipline, clubs, awards, etc.)

Ever Suspended/expelled?______For What?______Do you have any known learning disabilities Specify Were you enrolled in Special Education classes Have you ever been psychologically tested By whom Reason Future training and education desired

V. EMPLOYMENT Current source(s) of income Total amount of income Present employer Address Phone Date began employment Wages Job title/duties Immediate supervisor Does employer know about this offense Comments

Previous Employment: Employer Address Job Description Salary Dates of Reason for Employment Termination

Have you ever held a job for one year or longer?______Have you ever been fired from a job?______Why?______Do you get along with your boss/co-workers?______

VI. MILITARY Branch: Service #: Method of entry: Date entered: Date discharged: Highest Rank: Type of Discharge: Locations of Service: Special training received: Disciplinary actions: Medals, commendations, etc.: Service connected injuries/disabilities (describe): Eligible for benefits: Receiving benefits (specify): Additional comments:

VII. FINANCIAL STATUS

Do you have a checking or savings account?______Credit Cards?______Douglas County Probation, Parent Interview Worksheet, Page 3 Ever had a check returned for non-sufficent funds______Ever filed for bankruptcy or considering filing?______Are you behind in any current payments?______Any bills sent to collections?______Are you able to maintain your monthly expenses______

VIII. FAMILY INFORMATION

Are your parents: Single Married Divorced Separated Widowed

Father Mother Address Phone DOB DOB Employment

Remarried Yes No When? Step-Mother Step-Father Address Phone DOB DOB Employment

Details on any Alcohol/Drug/Mental Health/Criminal history of parents:

Have you ever been abused by parents: Specify by whom: Have you ever witnessed a family member being abused? Describe Relationship with parents and/or step-parents (include frequency of contact):

BROTHERS AND SISTERS: NAME AGE ADDRESS PHONE EMPLOYMENT SPOUSE

Details on any Alcohol/Drug/Mental Health/Criminal history of siblings:

Which sibling are you closest to: Relationship with sibling: Other relatives with whom you have a relationship (grandparents, aunts, uncles)?______

IX. PERSONAL INFORMATION Are you: Single Married Divorced Separated Widowed Current Spouse Date of Birth Address Phone Employment Salary Place of Employment Shift/Hours Douglas County Probation, Parent Interview Worksheet, Page 4 Marriage Date Place of Marriage Does spouse use alcohol or drugs: If so, describe use: Has spouse received Mental Health counseling: If so, describe:

Has spouse ever been arrested: Explain/Comments :

Relationship with spouse/significant other: If not married, are you involved in a personal relationship? Name Date of Birth Address Phone Employment Salary Describe relationship: Does Significant Other use alcohol or drugs: If so, describe use: Has Significant Other received Mental Health counseling: If so, describe:

Has Significant Other ever been arrested: Explain/Comments :

Are you satisfied with current status (married, single)?______

PRIOR MARRIAGES: Ex-Spouse’s present name Address Phone Who has custody of any children Visitation Was support ordered What State/County Amount Are payments current Any incidents of violence with this person? Any arrests associated with this person? Has DCFS been involved with your family? Other marriages (Include names, addresses, dates, custody, support, etc.)

Have you ever had an Order of Protection ordered against you? Describe Have you ever been ordered to have “No Contact” with a person? Describe CHILDREN: NAME ADDRESS AGE SPOUSE

Details on any Alcohol/Drug/Mental Health/Criminal history of children:

Relationship with children (include frequency of contact):

X. HEALTH

A. PHYSICAL HEALTH

Douglas County Probation, Parent Interview Worksheet, Page 5 Overall physical condition Handicaps or disabilities Describe History of serious illness or injury Describe Currently under doctor’s care Why? Physician’s name and location Currently taking medication What?

B. MENTAL/EMOTIONAL Present mental/emotional state Any long term depression Under what circumstance Do you feel you are under an abnormal amount of stress? Describe How do you cope with stressful situations?

Any difficulty controlling anger Under what conditions Family/marital problems Describe Have you ever attempted suicide? Describe Have you ever thought about or talked about killing yourself or others? Describe Other Problems Are you presently receiving counseling Where Reason For how long Counselor Have you ever received counseling In-Patient Out-Patient Both When Where Reason Other treatment or counseling

C. DRUG USAGE Never used Experimented 1-2 times Not currently using Currently using Most frequently used drug Frequency of usage Last date used Other drugs used and frequency: Dollar amount spend on drugs: Occasions for usage: Usual place of usage: Home Friend’s house Parties Car No set place Usual style of usage: Alone With friends With spouse Special Occasions Parties only No set style: Describe behavior when using (i.e. aggressive, quiet): Do you feel drug usage is or has caused problems: How: Do you feel you are addicted or dependent on drugs:

Have you ever committed a crime while under the influence of drugs: Have you ever committed a crime to obtain money to buy drugs: Have you ever been arrested for possession or sale of drugs

Age of first usage: When was last usage: Has usage increased or decreased in past two years: Explain: Any history of overdose: When: What drug: Comments: Additional information: If not presently using drugs, what drugs have been previously used?:

Describe frequency of usage: Age of first usage: When was last usage: Why did you quit using drugs:

HISTORY OF TREATMENT FOR DRUG USAGE: In-patient Out-patient Both A.A./N.A. Remedial Education Douglas County Probation, Parent Interview Worksheet, Page 6 Treatment Agency When Type of Discharge Self Referred Court ordered Other (explain) Additional Treatment

D. ALCOHOL USAGE: None Currently not using Currently using Usual drink: Frequency: Amount per occasion: Dollar amount per week: Usual place of usage: Home Friend’s house Parties: Car: No set place Usual style of usage: Alone With friends With Spouse Special Occasions Parties only No set style Describe behavior when drinking(i.e. aggressive, quiet): Do you feel you are an alcoholic: Do you feel alcohol usage is or has caused problems: How: Have you experienced memory loss or blackouts from drinking: Have you gotten into fights while drinking: Has drinking caused problems at home, school or work: Have you injured yourself or been involved in an accident after drinking: Explain:

Does spouse or parents express concern or complain about your drinking: Do you ever feel bad about your drinking: Have you ever committed a crime while under the influence of alcohol: Have you been arrested for Illegal Transportation, Unlawful Possession of Alcohol or DUI: Specify: Age of first usage: When was last usage: Has usage increased or decreased in past 2 years: Explain: Any history of overdose: When: What drug: Comments or additional information: If not presently using alcohol, describe extent of previous usage: Why did you quit?:

HISTORY OF TREATMENT FOR ALCOHOL USAGE: In-patient Out-patient Both A.A./N.A. Remedial Education Treatment Agency When Type of Discharge Self Referred Court ordered Other (explain) Additional Treatment

XI. AGENCY CONTACTS

Specify services you have received from other agencies (include dates, name facility and county): Mental Health Center: Public Aid: General Assistance: JTPA - Job Service: DCFS: Family Service Agency: Community Counseling Center: TASC: Other Agency: Other relevant Agency information:

Douglas County Probation, Parent Interview Worksheet, Page 7 XII. INTERESTS AND LIESURE TIME ACTIVITIES

Describe outside activities: Describe Hobbies: Involvement with any groups, organizations, church: Associates: What activities do you usually do together and where: Have your associates been in trouble with the law: Essentially non-criminal Mixed Mainly Criminal

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

______Signature Date

Douglas County Probation, Parent Interview Worksheet, Page 8