Male

Female

Yes

No

/

/

-

-

Yes

No

(

)

-

(

)

-

(

)

-

Single

Married

Divorced

Separated

Widowed

/

/

Yes

No

/

/

Yes

No

/

/

Yes

No

/

/

Yes

No

/

/

Yes

No

/

/

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

/

/

/

/

Yes

No

Good

Fair

Poor

Disabled

Yes

No

Yes

No

ADHD

Austism

Cerebral Palsy

Intellectual Disability

Hearing Loss

Learning Disability

Vision Impairment

Yes

No

Yes

No

/

/

/

/

Major Depression

Borderline Personality Disorder

Bipolar Disorder

Schizoaffective

Panic Disorder

Anxiety

Schizophrenia

Other

Yes

No

/

/

/

/

(

)

-

SSI/Disability

Laid Off

Unemployed

Student

Family/Friends Assist

Alcohol Never Use

Alcohol Currently Use

/

/

Marijuana Never Use

Marijuana Currently Use

/

/

Cocaine (Powder) Never Use

Cocaine (Powder) Currently Use

/

/

Cocaine (Crack) Never Use

Cocaine (Crack) Currently Use

/

/

Heroin Never Use

Heroin Currently Use

/

/

LSD (Acid) Never Use

LSD (Acid) Currently Use

/

/

Ecstasy Never Use

Ecstasy Currently Use

/

/

Methamphetamines Never Use

Methamphetamines Currently Use

/

/

Fentanyl Never Use

Fentanyl Currently Use

/

/

Other 1 Never Use

Other 1 Currently Use

/

/

Other 2 Never Use

Other 2 Currently Use

/

/

Other 3 Never Use

Other 3 Currently Use

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

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/

/

/

Less than 12th grade

High School graduate

GED

College

Yes

No

Yes

No

Yes

No

full-time

part-time

No, I am on disability

No, I am retired

No, not currently employed

Yes

No

1 Very Easy

2

3

4 Very Difficult

1 Not Satisfied

2

3

4 Very Satisfied

1 Cannot Pay Bills

2

3

4 Can pay bills and have extra money

1 Not satisfied

2

3

4

5 Very satisfied

1 No support

2

3

4

5 great deal of support

1 Not satisfied

2

3

4

5 Very satisfied

1 strongly agree

2

3

4

5 strongly disagree

1 never only small lies

2

3

4

5 it's ok to lie

1 strongly agree

2

3

4

5 strongly disagree

1 strongly agree

2

3

4

5 strongly disagree

1 walks away

2

3

4

5 first to get into it

1 strongly agree

2

3

4

5 strongly disagree

-

-

/

/

1. Pretrial release supervision and monitoring of release conditions

2. Probation Supervision and monitoring of conditions of supervision

3. Other, please specify:

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