OFFENDER NEEDS ASSESSMENT

1. Do you have a high school degree or a GED? Yes No

2. Are you currently employed? Yes No

3. Does your salary allow you to meet your financial obligations (including court
ordered sanctions)? Yes No

4. Describe your financial situation…

Excellent Good Fair Poor Severe difficulties

5. Have you filed for bankruptcy within the past seven years? Yes No

6. Describe your marital/family relationships?

Excellent Good Fair Poor Severe difficulties

7. Have any of your friends been in jail or arrested? Yes No

8. Have any of your family members ever been in jail or arrested? Yes No

9. Is there a co-defendant in this case? Yes No

10. Are you currently involved with or have you ever been involved in a gang?
Yes No

11. Have you ever been treated or diagnosed with a mental health issues? Yes No

12. Do you take any medications for mental health issues? Yes No

13. Have you ever attended in-patient or residential treatment for substance abuse?
Yes No

14. Have you ever attended in-patient or residential treatment for mental health issues?
Yes No

15. How many alcoholic beverages do you consume on an average week?

______________________________________________

16. Which best describes your previous alcohol consumption?

Never Occasionally (monthly or less) Weekends only Daily

17. If this current charge is DUI related, what was the BAL result?
_____________ or refused BAL test________

18. What drugs have you tried in the past?

None Marijuana Cocaine Heroin Meth Ecstacy LSD

19. What drugs have you used within the past year?
______________________________________________

20. Do you have any health problems that interfere with daily activities?
______________________________________________

21. Do you have any learning disabilities, reading or writing issues that interfere with
your daily activities? Yes No

22. Have you ever been a victim of a sexual offense? Yes No

If yes, did you seek treatment? Yes No

23. Have you ever been arrested for a sexual offense? Yes No

If yes, were you convicted of the charge? Yes No

24. Do you have any critical issues that you need to discuss with an officer today?
Yes No

25. How old were you at the time of your first conviction (including any juvenile
charges)?
______________________________________________

26. How many times have you been on Probation previously?

None One Two or more

Were you ever violated from Probation? Yes No