If you are convicted of a felony in Utah, and in many cases a class A misdemeanor, the court may require you to meet with adult probation and parole, which is the entity responsible for supervising your probation. Before AP&P will take responsibility for your probation, you will be required to fill out a questionnaire. Below is an example of the questions you will be required to answer for AP&P.
Describe your current PHYSICAL and MENTAL conditions:
Are you currently under a doctor’s care? Yes_____ No______ Physician’s Name: __________________
Reasons for treatment __________________________________________________________________
Are you taking prescription medication? Yes_____ No_____ If yes, what kind and why?
Have you ever received treatment for mental/emotional problems? Yes____No____ If yes, why?
Have you been diagnosed with a mental illness? Yes_____No_____ If yes, what? When?
Do you still suffer the symptoms? Yes_____No_____
IF you are not receiving counseling, would you like to? Yes_____No_____ If yes, why?
Do you or have you in the past thought about suicide? Yes_____No_____
Have you ever attempted suicide? Yes_____No_____ If yes, explain:
Have you been physically, mentally, or sexually abused? Yes_____ No_____ If yes, explain:
What would you like to change most in your life?
How do you feel about what you did? Do you think it was wrong?
Who/what was the reason/problem why this happened?
PRESENTENCE REPORT QUESTIONNAIRE
Name:
Date of Birth:
What other legal names have you had?
Other names used (maiden name, nickname, etc.)?
Have you been under our jurisdiction as an inmate on parole or probation? If yes when and what was you offender number?
SSN:
Have you ever used another SSN? If yes, what was the number:
Full Address:
Phone:
Prosecuting attorney:
Defense attorney:
Martial Satus: Never Married Married Divorced Separated Widowed Common Law
EVALUATION ASSESSMENT AND PROBLEM AREAS
How many people in your life do you consider to be close friends?
What type of things do you do with your friends?
How many of your friends have been in trouble? None Few Some Most
Do you have acquaintances that have been in trouble with the law? Yes_____No_____
Who do you have in your life that has never been in trouble and is always iwlling ot help you out and support you?
Do you belong to and are actively involved in any community, groups, organizations, clubs or churches? Yes_____No_____ If yes, please describe them and your involvement:
Describe what you like to do in your spare time:
What have you done since your arrest to fix the problem?
What have you learned from this experience?
Do you need to change the direction of your life? Are you headed for trouble? Explain:
What changes do you need to make so this doesn’t happen again?
How hard are you willing to work at changing and not having any more problems like this?
What do you see your future being like? 1 year, 5 years from now?
Do you think your sentence will be fair?
What should the judge do? What kind of sentence do you deserve – prison, probation, jail, counseling, fine restitution, home arrest? What do you think would be fair?
If placed on probation, what do you think the benefit and disadvantages will be?
PLEA AGGREEMENT
Original charge:
Pled to what:
List charges dropped:
DEFENDANT’S STATEMENT
STATEMENT OF THE OFFENSE: This statement should contain your version of what happened related to the offense and should include you reason for your involvement and how you feel about what happened. How do you feel about the crimes you’ve committed? Do you think it was wrong? Do you feel sympathy for the victims of your crimes? Date:___________ Signature:___________________________
CUSTODY STATUS
Were you incarcerated for the present offense? Yes____ No_____
If so, how many days did you spend in jail?
Indicate how and when you were released from jail (did you post bail? Name of bail bondsman etc.):
CO-DEFENDANT STATUS
Was anyone else arrested with you? Yes____No____ If yes, list their names and level of involvement:
CRIMINAL HISTORY
Were you ever arrested or stopped by the police for law violations under the age of 16? Yes____No_____ Explain:
Were you ever incarcerated upon conviction in a jail/prison or juvenile detention? Yes____No____ Explain:
If yes, were you ever punished for violating the rules while incarcerated? Yes____No____ If yes, list the rule violations:
Have you had any escape or attempted escape form a youth or adult correctional facility, including institutional and residential facilities? Yes____ No____
Do you have a record or history of assault or violence? Yes____ No____ Specify:
Please list below all previous referrals as a JUVENILE (under age `8). Also include referrals outside the State of Utah.
Date Arrested Police Dept/City Offense Age Sentence (Fine, Probation Jail)
Please list below all previous arrests as an ADULT (age 18 and over). Also include arrests outside the State of Utah. Provide a complete list of all arrestes even if charges were dismissed.
Date Arrested Police Dept/City Offense Age Sentence (Fine, Probation Jail)
PENDING CASES
Do you have an unresolved court cases or any outstanding tickets or warrants? Yes____ No____ If yes, explain what they are for:
GRAND AFFILIATION
Are you now or have you been involved with a gang? Yes____ No____ If yes, list name of gang and your level of involvement:
PROBATION/PAROLE HISTORY
Have you been on probation or parole in the past? Yes____ No____ If yes, please explain:
Are you currently on probation or parole? Yes____ No____
What were/are the dates or your probation/parole?
If you are or have been on probation or parole, list any violations of your probation/parole conditions you had:
Where were/are you on probation (city, state, district, etc.)?
VICTIM IMPACT STATEMENT AND RESTITUTION
Was there a victim in this offense? Yes____ No____
If yes, do you know the victim? Yes____ No____ Who was the victim?
Did the victim experience injury, loss, or damage as a result of your conduct? Yes____ No____
If yes, please explain what you know about that:
How do you feel about the injury, damage, or loss of the victim(s) experienced in this offense?
What is your plan to make restitution, if owed?
LIFE HISTORY AND CURRENT LIVING SITUATION
Place of Birth:
Are you the oldest, second, third, fourth, last child etc.?
Blood father’s name: Occupation/type of work:
How many times has your father been married?
Blood mother’s name: Occupation/type of work:
How many times has your mother been married?
If your parents are divorced, how old were you when it happened?
As best you know, why did they get divorced?
Name of stepparents:
List the members of your immediate family: Parents, stepparents, adoptive parents, brothers, and sisters, stepbrothers and sisters, and adoptive brothers and sisters.
Name Relationship Age Address/Phone #
Were you adopted? Yes____ No____ How old were you when adopted?
Name of parents that adopted you:
Did you ever live in any foster placements? Yes____ No____
How was/is your parents’ marriage?
How do you get along with your father?
How do you get along with your mother?
Describe any unusual problems your parents have had, such as alcohol abuse, drug abuse, legal problems, mental illness, history of being unemployed, abusive, etc?
Describe any unusual problems your brothers or sisters have had, such as alcohol abuse, drug abuse, legal problems, mental illness, history of being unemployed, abusive, etc?
How did you get along with your parents, brothers/sisters while growing up?
Describe your family: (normal, dysfunctional, weird, close, distant, strict, permissive solidarity/cohesiveness etc.)
What was hardest/worse/most difficult thing about your family life? The best thing about your family life?
In what type of economic environment were you raised (lower, middle or upper income)?
Where did you grow up? Where did you live when you were younger?
List all the places you have lived from childhood to present. Specify time period for each move.
Who raised you, primarily? (Give names and relationship)
1) Please list first and last names of CHILDREN to FIRST marriage or common law relationship and their ages.
Child’s Name Birth Place Birth Date Age
2) Please list first and last names of CHILDREN to SECOND marriage or common law relationship and their ages.
Child’s Name Birth Place Birth Date Age
3) Please list first and last names of CHILDREN to THIRD marriage or common law relationship and their ages.
Child’s Name Birth Place Birth Date Age
Please describe your present relationship with your spouse/common law partner:
How does your spouse/partner feel about this present offense?
Does your spouse or significant other have a present or past criminal record? Yes____ No____ If yes, please explain:
Besides your immediate family, list other relatives you have regular contact with:
Name Relation Address Phone Number
What particular problems did you encounter as a child, if any?
Describe your childhood in general
How do you feel about your early home life (during elementary school etc.)?
Do you feel bad/guilty about how you have treated your family?
Are you mad at any family member? Why?
During your life have you experienced any traumatic/unusual/weird/bad things/problems such as: accidents, anyone close to you die unexpectedly, suicides, abuse of any type – verbal, physical, mental, sexual etc.? Explain:
How old were you when you left home? Why?
Are you currently: Married Single Divorced Separated Living with/Companion Common Law
If you are single do you have any plans for marriage in the near future? Yes____ No____ If yes, to whom?
Please list all PREVIOUS and PRESENT marriages for YOURSELF.
Spouse’s Name Date/Place Marriage Date/Place Divorced or Deceased
If divorced, please list reason(s) for divorce:
Please write a BRIEF HISTORY OF YOUR LIFE beginning with your birth, up to the time you were arrested for the present offense. If your life has changed significantly since your arrest please explain:
Who do you live with?
How long have you lived at your current address?
How many addressed have you had in the last 12 months?
What kind of neighborhood do you live in?
Do you consider it to be a high crime neighborhood?
Do you like where you are living? Yes ____ No____ If no, explain:
EDUATION
Please list high schools, trade schools and institutions of higher learning you’ve attended.
School Name Location #Yrs Attended Grade Completeed Date Left Graduate?
What was the highest grade you completed?
What year did you graduate from HS, college etc.?
Do you have a GED? Yes____ No____ If so, where did you get it?
If you left school before graduation, what were your reasons?
What kind of grades did you get? A B C D F Other: explain
Have you ever been suspended or expelled from school? Yes____ No____ If yes, explain:
Did you ever fail any grades where you were held back? What grade?
Do you have any learning disabilities? Yes____ No____ If yes, explain:
Did you ever have special education help? What areas?
How did you get along with your teachers?
How did you feel about school? Like or dislike it?
What education/training have you had since high school?
At this point in your life would you like more education/school?
What would you like to study?
EMPLOYMENT
How many jobs have you had in the last 10 years?
What is the longest you have held a job?
List the places you have worked, starting with the most recent (or current) job:
Employer & Address Wage Job Title Date Started/End Reason for Termination
How many hours a week do you work?
How many days have you missed during the last month?
Do you like your job?
Have you ever been fired or resigned from any job? If so, how many times?
Describe how you get along with the people at work:
Describe how you get along with your supervisor:
What are you career goals?
Do you have any physical work limitations?
FINANCIAL INFORMATION
What is your current monthly household income? $
Does your spouse work? Yes____ No____ If yes, where?
What would you estimate your total monthly expenses to be? $
What is the total or your debts? $
Do you have any savings?
Do you own a credit card(s)? Yes____ No____ If yes, total amount due on combined credit cards: $
Do you have any past due bills? Yes____ No____ If yes, explain:
Have you ever filed bankruptcy? Yes____ No____ When?
Are you planning to file bankruptcy? Yes____ No____
Have you ever had property repossessed? Yes____ No____ If yes, what?
In the past 12 months, have you had to rely on food stamps, worker compensations, unemployment or other social assistance to meet your basic needs? Yes____ No____
Is your income adequate to meet needs?
Describe your financial situation (do you us e a spending plan/budget)?
Have you ever issued bad checks?
Are you ordered to pay child support? Yes____ No____ Are you current on child support?
What is your current credit rating? Bad Fair Good Excellent Unknown
Do you have a private medical insurance provider? Yes____ No____
If you have a private medical insurance provider, please include the following information listed below:
Primary Medical Insurance Provider:
Primary Medical Insurance Policy #:
Name of Person Who Holds Policy:
Secondary Medical Insurance Provider:
Secondary Medical Insurance Policy #:
Name of Person Who Holds Policy:
SUBSTANCE ABUSE HISTORY
Have you or do you use alcohol? Yes____ No____ If yes, explain below.
Types of Beverages Age First Used Frequency of Use Amount Last Used
How old were you when you began using alcoholic beverages?
How did you get it the first time?
How old were you when you started to drink regularly? (every day, weekend, month etc.)
How often do you drink now (daily, weekends, monthly, special occasions, etc.)?
What do you drink?
Who do you drink with (alone, family, friends)?
Where do you usually drink (home, bars, parties, etc.)
Do you have a problem with the use of alcohol?
Do you feel you have ever abused alcohol? Yes____ No____ If yes, have you ever received counseling for alcohol abuse? Yes____ No____ If yes, where and when?
Would you be willing to participate in alcohol abuse counseling now? Yes____ No____
Were you drinking when you committed this offense? Yes____ No____
List any other offenses you have committed while under the influence of alcohol:
Are you now or have you in the past abused prescription drugs? Yes____ No____ Date last used:
How old were you when you first used drugs?
Do you currently have a drug problem? Yes____ No____
Have your drug using habits changed over the last year? Yes____ No____ If yes, explain:
List below any ILLEGAL DRUGS you are currently using, or have ever used, experimented with, or even tried one time:
DRUG: Amphetamine Barbiturates Cocaine Crack Cocaine Heroin Inhalants LSD Methamphetamine Opiates Other Hallucinogens Prescription MDMA GHB Other
SUBSTANCE ROUTE: Inhalation IV Inject Nasal Non-Iv Inject Oral Smoke Other
Drug Age First Used Frequency Used Amount Substance Last Used
What is your drug of choice?
How much do you usually use at one time?
How do you use it?
How much do you use it at one time?
During the last 30 days, how many times have you used?
The longest you have gone without (stopped) using any drugs is?
Your heaviest use was at age:
At the time, how much (quantity) were you using at a time?
What do drugs do for you? The good thing? Why you continue to use?
Do you have a drug problem?
Have other people talked to you (complained to you) about your use?
Please circle any of the following problems you have had due to alcohol or drug use in the past year or so:
Law Violations Family Problems School Problems Medical Conditions Use upon waking up Drinking to unconsciousness/blackouts Past Treatment Failure Financial Problems Due to Use Use while in Jail Sneaking drinks or “fixes” Frequent use/High tolerance
Have you quit using for a month or week to prove you could and then started again? Yes____ No____
Does it seem that you need more or use more chemicals now then you use to? Yes____ No____
Have you experienced a loss of memory while using, for example, maybe you can’t remember driving home after using or what you said at a party? Yes____ No____
Do you spend a lot of time thinking about using drugs or alcohol during the day? Yes____ No____
Have you tried to stop using but couldn’t? Yes____ No____
Have you lied to others about your use or tried to hide your use? Yes____ No____
Have you regretted what you’ve done while using? Yes____ No____
Have you started to withdraw from others to protect your use? Yes____ No____
Do you use to cope with life? Yes____ No____
Has your chemical use ever put yourself or others in danger? Yes____ No____
How have you supported your habit?
Have you done anything illegal to get money for drugs like theft/forgeries/dealing etc.?
Do you have any prior drug arrests? Yes____ No____ If yes, how many?
Have you ever attended drug counseling? Yes____ No ____ If yes, list when and where you attended:
Are you going to counseling now?
Would you be willing to participate in a drug abuse counseling program? Yes____ No____
Have you thought about stopping the use of all drugs? Explain:
Were you using any type of drug when you committed the present offense? Yes____ No____ If yes, what drug(s) were you using?
COLLATERAL CONTACTS
Besides your immediate family, list other relatives you have regular contact with:
Name Relation Address Phone Number
Other comments you would like to make:
