Client Name: * First Last

Client Date of Birth: * MM / DD / YYYY

Parole Officer: *

Please select your Parole Officer from the drop down list.

Other Names Used:

Current Living Situation:

What type of housing are you currently living in? *

Current Address: *

Mailing Address (if different):

Vehicle Make/Model: *

Vehicle Color: *

Vehicle Plates: *

My Contact Phone Number: * ### - ### - ####

Message Phone (if different): ### - ### - ####

Email: *

Names of all People living at residence: *

Employment / Education and Financial:

Are you currently employed? *

Are you currently attending school? *

Attitude / Orientation:

What happened during the past 30 days that went well? How did it make you feel? *

What happened during the past 30 days that didn't go well and how did you deal with it? *

What affect has your attitude and behavior had on your friends or family? *

Friends / Associates:

Who is your closest friend? *

Time spent together per month: *

Describe a healthy activity you participated in this month with a friend or associate: *

Describe a risky situation you may have been in with your friends and how you handled it: *

Family / Relations:

Who is your significant other? *

In the past 30 days my family member/significant other and I had fun doing: *

Describe any problems/arguments you have had with a family member/significant other during the past 30 days? *

Liesure & Recreation:

My hobbies and interests are: *

How did you use your free time during the past month? *

I'm involved in these activities: *

Treatment Status:

How much time do you have clean and sober? *

Currently in Treatment? *

Describe a high risk situation you experienced in the past 30 days and how you would avoid or better cope with that situation: *

Treatment Provider: *

Counselor: *

Health:

Describe how your physical/mental health has been during the past 30 days: *

Are you currently seeing a doctor? *

Work Crew / Community Service:

Days/Hours Worked last month: *

Days/Hours remaining: *

Placement Site: *

Police Contact - Please explain any police contact: *

Other:

List your accomplishments this month: *

What do you think needs to change to prevent further problems in you life? *

What skills or risk domains are you working with your PO to improve upon? *

Things I have done since my last office visit to reduce my risk of re-offending? *

Please list any concerns you would like to discuss with your PO: *

Comments: