Treatment Court Application General Information Name: DOB: Last / / Sex: M F First Date: _ Middle Primary Language: Tribal Benefits Eligible? Significant Other? _ Do you ever feel afraid of you current partner? Y N Y N Ethnicity (Caucasian, African American, etc): Marital Status: Length of Current Relationship: Did you serve in the Military? Current Address/ Physical Address: Is this your Primary Address? How long? Others in household: Mailing (if different): _ E-mail: Cell Phone: ( ) City Phone: ( Message Phone :( _) _ Y Y N VA Eligible? City Y N State Zip N Type of Residence (apt, rental, etc) Relationship: State Zip _) If the message phone is not yours, who owns it? Emergency Contact: Name: First Relationship: Ok to contact? Y N Phone: ( ) ) _- Middle Last Alternate Contact Number: ( Legal Information: Please list every county/state where you have had charges or legal trouble: Where (what courts) do you have pending charges? Probation Officer? Attorney? Child Welfare Worker? Treatment Court Application Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 08/21/15 Financial Information Do you owe Child Support? Do you owe money to other courts or counties? Are/will your wages be Garnished? Why? Y Y Y N N N If so, how much? If so, how much? Uncertain How much per month? Transportation Do you have reliable Transportation? Current Insurance? Y Y N N Do you have a valid ODL? Y N If suspended, or revoked please list all courts where you have outstanding cases or fines: Education Last Year Completed? _ Current School? Estimated Graduation Date / High School Grad: Grade: / Y N GED: Y N College Degree: Y N School Contact Name: Employment Information Are you employed? Primary Employment: _ Employer Contact Name: Income: Per: Y N If no, source of income. Occupation: Employer Contact Number: ( Approximate Hrs per Week: _ Primary Skills/Occupation: Y N _) How long? / Longest you have kept employment? Are you receiving public assistance (TANF)? If yes, Caseworker's Name: Additional Sources of Income Medical/ Mental Health History Medical Insurance: Physician Name: Physician Address: Physician Phone: ( Treatment Court Application Facility: City: ) Last Contact: Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com State: Zip: 08/21/15 Pregnant? Y N Significant Other Pregnant? Y N Due Date? / _/ Any Medical Conditions/Comments? Mental Health: Do you have a mental diagnosis? Have you ever done treatment for a mental illness? Do you currently have a Mental Health Counselor? Have you ever been hospitalized due to mental illness? Have you ever taken medication for mental illness? Please list all mental health medication you are currently taking? Y Y N N Y N Substance Abuse History Longest Clean and Sober Period since starting use (in months): Drug Frequency (Daily, 1 x per week, etc) Age Began Using Route (IV, Snort, eat, etc) Date of Last Use Rank (order of preference) Alcohol & Drug Counselor: Phone: ( _) - Agency: Have you attended addiction treatment in the past? Needle Use in Past Year? Did your family use growing up? Reasons/ Benefits of use/Comments? Y Y N N Y N How many times? Y N Use by Partner or Housemate? . Treatment Court Application Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 08/21/15 Goals/Hobbies/Personal Information How do you like to spend your free time? What type of work are you good at, or what type of employment do you enjoy? _ Please describe something you are proud of accomplishing? What are some personality traits that you have that you think will help you in your life? Do you have anyone that you look up to and respect? If so, why? Y N What do you expect to get out of treatment court? What goals do you hope to accomplish while participating in a treatment court program? As a minor, were you in foster care? Y___ N___ If so, at what age? __________ Comments/Other: Treatment Court Application Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 08/21/15 Minor Children ­ please list all children, even if they are not living with you. Please include children that are with the other parent, children in a guardianship or children that have been adopted. Name: Address: Phone: (_ _) -__ DOB: City: Who has legal custody? Phone: ( _) Y N _/ / _ Age: State : Sex? Zip: M F School Name: Other Parent's Name: Lives in Household? DHS Involved? Who are they living with? Date Children Were Taken: Times in Foster Care: _ Check all that apply: Notes/ Special Needs: No Contact Order _/ CASA: Y Y N N Are they actively involved with the child? Frequency of Contact _ / Incarcerated Uses Drugs/Alcohol On Probation Where would your child live if you were required to do residential treatment? Name: Address: Phone: ( ) -_ DOB: City: _/ / _ Age: State : Sex? Zip: M F Who has legal custody? Phone: ( _) Y N School Name: Other Parent's Name: Lives in Household? DHS Involved? Who are they living with? Times in Foster Care: _ Check all that apply: CASA: No Contact Order Y Y N N Are they actively involved with the child? Frequency of Contact _ Date Children Were Taken: _/ / On Probation Incarcerated Uses Drugs/Alcohol Treatment Court Application Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 08/21/15 Notes/ Special Needs: Where would your child live if you were required to do residential treatment? Name: Address: Phone: ( ) -_ DOB: City: _/ / _ Age: State : Sex? Zip: M F Who has legal custody? Phone: ( _) Y N School Name: Other Parent's Name: Lives in Household? DHS Involved? Who are they living with? Times in Foster Care: _ Check all that apply: Notes/ Special Needs: No Contact Order Y Y N N Are they actively involved with the child? Frequency of Contact _ Date Children Were Taken: CASA: _/ / _____________________ Incarcerated Uses Drugs/Alcohol On Probation Where would your child live if you were required to do residential treatment? Name: Address: Phone: ( ) -_ DOB: City: _/ / _ Age: State : Sex? Zip: M F Who has legal custody? Phone: ( _) Y N School Name: Other Parent's Name: Lives in Household? DHS Involved? Y Y N N Are they actively involved with the child? Frequency of Contact _ Treatment Court Application Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 08/21/15 Who are they living with? Times in Foster Care: _ Check all that apply Notes/ Special Needs: CASA: No Contact Order Date Children Were Taken: _/ / On Probation Incarcerated Uses Drugs/Alcohol Where would your child live if you were required to do residential treatment? Treatment Court