SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO Date: Application for Family Dependency Treatment Court (FDTC) Parent's Full Name Date of Birth Gender Male Female Phone Number: EMail Address: Ethnicity Caucasian Hispanic African American Asian Other: **Only list children with open dependency case Case Number Child's Full Name Date of Birth Gender Male Male Male Male Female Female Female Female Drug Testing: Frequency: Therapy: No No Yes Yes x wk Case Plan: FM Self-Help Meetings: A.A. Other: DV Allegations: No FR No Yes Services for Visitation Yes N.A. No Yes No Yes Frequency: x wk Parent's Attorney: Have you had an ASI Assessment? Drug(s) of Choice: Alcohol Amphetamine Heroin YES Phone: NO, but I have an appointment on: Methamphetamine PCP Marijuana No Yes Prescription Drugs Cocaine Other (Please Specify): If Yes, when (List Dates and Duration): History of Any Prior Treatment? Are you currently pregnant? YES No N/A Do you have health insurance? YES No What is your current living situation? House, Apartment, Mobile Home Residential Treatment Facility Transitional Housing Is this housing safe and stable? YES Residential Hotel, Rooming House Emergency Housing/Shelter Other (Please Specify): No Why? Homeless Jail/Prison Decline What is your highest education level achieved? No formal schooling High School Diploma th grade Less than 9 Some college or technical school Some high school Associates or technical degree Are you currently employed? FOR COURT USE ONLY: YES No Accepted Bachelor's Degree Graduate Degree Declined Applicant is: Not Accepted APPLICATION REVIEW SET IN DEPT. PJV-45 E12-13 at 3:00 PM, on / / / (date) F.D.T.C. Application for Family Dependency Treatment Court American LegalNet, Inc. www.FormsWorkFlow.com