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Home My WebLink AboutPSI Questionnaire - English 1 Questionnaire 2.0 - 2021 PRESENTENCE INVESTIGATION PERSONAL HISTORY QUESTIONNAIRE Legal Name: Last Name First Name Middle Name Other names you have used (Maiden Name/Former Married Name/Birth Name/Alias/ Nicknames, etc): Circle most appropriate: Never Married Married Divorced Separated Widow(er) Live-In Partner Physical Address: ______ Number Street Name Apt/Unit# City, State Zip Code Date you moved into your current residence: Your Telephone #: ___________ ____ Your email address: ____________________ Message #/Contact Name: ________________ ________________________ Social Security Number: _______________ Other #s used: _____________________ Sex: Height: Weight: Hair Color: Race: Eye Color: _________ Glasses: _____ Contacts: __ ____ You are (circle one): LEFT-HANDED RIGHT-HANDED BOTH Date of Birth: ________ Age: ___ Other dates of birth you have used: ___________ Place of Birth: _______________________________________________________ City State Country U.S. Citizenship: Y N Other Citizenship (if any): If born outside the U.S. and you obtained citizenship, when was it obtained? Resident Alien – year obtained __________ Number(s) __________________________ Do you have current immigration detainer? Y N Have you ever been deported? Y N If yes, when and to where? Do you have a valid driver’s license? Y N If yes – Issuing State 2 Questionnaire 2.0 - 2021 HISTORICAL LEGAL INFORMATION Age at first contact with law enforcement?____Reason?_______________________ Age at first arrest? ____ Reason____________________________________________ As a JUVENILE: Ever incarcerated/received detention? Y N If yes, when/why: On juvenile supervised probation? Y N If so, who was your supervising officer and how would you describe your experience? ___________________________________ Any probation violations? Y N If yes, what for? Did you ever escape or attempt to escape from a youth detention center or secure residential treatment facility? Y N If yes, from where? ________________________ Did you receive any disciplinary action for misconduct while housed in a secure facility, and if so, which state/facility and what was the action and sanction?_____________ _ Programs completed (estimate year and program name): ______________________________________ As an ADULT how many convictions do you have? _____ Are you currently on probation, parole, or court/pre-trial supervision? Y N If yes, who is supervising officer? _____________ _________________ Have you been on probation or parole? Y N If yes, where, and who was your supervising officer? _____________________________________________________ Any probation violations? Y N If yes, what for? Have you ever absconded supervision? Y N Describe your overall experience on supervision? ______________________________________________________________________ Have you ever been incarcerated as an adult? Y N If yes, list facility name(s), cities, and states where you have been in jail or prison: _____________________________ ______________________________________________________________________ 3 Questionnaire 2.0 - 2021 List any state where you have been arrested: __________________________________ Did you receive any disciplinary action for jail misconduct, and if so, which state/facility and what for/sanctions given? Jail/Prison programs completed (estimate year and program name): _______________ At any time in life, have you ever hit, kicked, or choked someone? Y N If yes, please explain: ___________________________________________________ _____________________________________________________________________ At any time in life, have you ever touched someone sexually without their consent? Y N If yes, please explain: __________________________ PRIOR ARREST AND CONVICTION HISTORY Include all arrests, charges, and adjudication/convictions for juvenile, misdemeanor, and/or felony crimes – INCLUDING crimes in other states Please use the back of this or other paper if you need more space. Arrest State Co-defendant(s) in this crime, if any: 4 Questionnaire 2.0 - 2021 YOUR DESCRIPTION OF THE CRIME Please explain HOW, WHEN, AND WHY the current crime(s) occurred. Be thorough, as this will be written word-for-word in your report. Include any probation/parole violation information. Were you under the influence of ALCOHOL or DRUGS when you committed this crime? If under the influence, identify substance(s): 5 Questionnaire 2.0 - 2021 COMPANIONS An acquaintance is someone whom you have met more than once A friend is someone with whom you spend your free time and whose opinion you value Were you with friends or acquaintances when you committed the current offense? Y N If so, who? ____________________________________________________________ Who do you consider to be your best friend(s)? ______________________________________________________________________ Who provides you the most positive support? __________________________________ Contact information for best friends/positive support: ____________________________ ______________________________________________________________________ Over the past year (or in the year prior to your arrest if you are incarcerated) estimate what percentage of your acquaintances have been involved in criminal activity (committing crimes, being arrested or using illegal drugs)? __________ friends ______________ Over the past year, estimate what percentage your acquaintances have been involved in regular community-based activities (volunteering, playing on an organized sports team, attending church, etc)? ___________ friends _______________ What type of community-based activities do you do with your companions and how often do you have contact? Are or were you a member of, or affiliated with, a gang? Y N Gang: ____________ How would you describe your association? PHYSICAL HEALTH How would you describe your current physical health? __________________________ Are you currently under a doctor’s care? Y N If yes, please list your doctor’s name and contact information: _________________________________________________ 6 Questionnaire 2.0 - 2021 Health Problem/limitation onset/diagnosis physician income Y/N procedure(s) (date and doctor) and current Prescribed medications: Medication Reason prescribed Prescribing Dr. Date of first use MENTAL HEALTH How would you describe your current mental health? _____________________________________________________________________ Do you feel you would benefit from mental health counseling at this time? Y N When/where, if ever, have you previously participated in counseling? ______________________________________________________________________ Any need for current evaluation (for anxiety/depression, etc)? If yes, please explain: Have you ever thought about and/or attempted to hurt someone else physically? Y N If yes, please explain _____________________________________________ Have you ever considered/attempted self-harm and/or suicide? If yes, please explain 7 Questionnaire 2.0 - 2021 Mental Health Diagnosis and treatment: Do you have any additional physical or mental health considerations/concerns you would like help to address? _______________________________________________________ OUTLOOK Looking back, how do feel about this crime and your actions? _______________________ ______________________________________________________________________ What do you think the most appropriate sentence would be? _____________________________________________________________ If you have a plea agreement, what do you understand it to be? _____________________________________________________________________ Do you feel your plea agreement is fair? Y N If no, what do you feel would be fair? ______________________________________________________________________ _____________________________________________________________________ What contributed to your legal problems? _________________________________________________________________ Mental health Year (estimate) List diagnosis and treatment facility length/kind of treatment (i.e. 6 months medication, counseling, etc.) Diagnosis ] Outpatient treatment episodes treatment episodes 8 Questionnaire 2.0 - 2021 What are you doing, or planning to do, to address these problems? ________________ What do you consider th e effects or possible effects of your crime on yourself or others or the community as a whole? __________________________________________________________________ FAMILY/MARITAL If you were adopted, at what age and by whom? Name of birth parents and any contact with them? _______________________________________________________ Were your parents married when you were born? Y N What year did your parents divorce or separate? ___________ Who primarily raised you? Father (full name): _____________________________________________Age: _____ Address: ___________________________________________Telephone: ________ Number Street City/State Zip Is your father an emergency contact: Y N What was your relationship like when you were young? ____________________________________________________________ Do you consider your dad a positive support now? Y N If not, why? ___________________________________________________ If yes, what type of (emotional/financial, etc) support? How often do you speak now? ___________ Mother (full name): _____________________________________________Age: ____ Address: ________________________________________Telephone: Number Street City/State Zip 9 Questionnaire 2.0 - 2021 Is your mother an emergency contact: Y N What was your relationship like when you were young? ___________________________________________________________ Do you consider your mom a positive support now? Y N If not, why? ___________________________________________________ If yes, what type of support? ______________ __________________________ How often do you speak now? Do you have any stepparents you would identify as an emergency contact (name/contact information)? __________________________________________________ Briefly describe your childhood and family relationships; any abuse (physical, emotional, or sexual) and what did you consider the best and hardest parts? ___________________________________________________ ____ _______________________________________________________ Siblings (sisters/brothers) Age Emergency Contact Y/N Describe your relationship with your siblings over the past year? ____ Describe your relationship with other relatives (cousins, grandparents, etc) over the last year? 10 Questionnaire 2.0 - 2021 Any other family members you would identify as an emergency contact or as supportive of you? _____________________________________________ Phone: If you were ever in foster care, what was the reason and for how long? Do your foster parents remain a positive part of your support system? Y N If so, name/phone: Does anyone in your family have a substance abuse issue (please describe)? ____________________________________________________________________ Has anyone ever hit, punched, kicked, or choked you? Y N Who/When and was it reported to the police? ______________________________________________________ Have you ever been touched sexually without your consent, and if so, was this matter ever reported to the police? __________________________________________________ Any members of your family, including spouse, who have a criminal record - note their name/relationship and crimes: SIGNIFICANT RELATIONSHIPS If single, rate your satisfaction with being single: VERY UNSATISFIED UNSATISFIED SATISFIED VERY SATISFIED Please explain: 11 Questionnaire 2.0 - 2021 CURRENT SIGNIFICANT RELATIONSHIP OR MARRIAGE Full Name: _____________________________________ Age: _____ Emergency Contact: Y N If m arried, date of marriage: ______________ Address: Telephone: When and how did you meet? ______________________________________________ Month/Year you became significantly involved: __________________ How would you describe this relationship and your satisfaction level in the relationship? Describe any mutual alcohol/drug use/abuse and/or physical abuse within the relationship? __________________ ___________________________________________________ Does this person have a criminal record? Y N Ever on probation/parole? Y N Who was/is the PO (if applicable) and which city/state/year? _____________________________________________________________________ PAST SIGNIFICANT AND/OR MARRIAGE RELATIONSHIPS Name/age and their current City/State and phone number Legally Married Date relationship started/ended Describe relationship (to include any substance use 12 Questionnaire 2.0 - 2021 CHILDREN Please provide ALL of your children’s information below. Use the back of this page if you need more space. Full Name and City/State where with this child and how often do you engage in these activities together? Who is the primary parent/guardian for your child/children? ____ If you have been ordered to pay child support, how much, $ and what State issued the order? _________ Do you have any past-due child support debt, please explain? If you ever have been involved with Health & Welfare or Child Services regarding issues of child protection (abuse, neglect, etc), please explain: ___________________ SUBSTANCE USE HISTORY ALCOHOL What age did you first drink alcohol? ______ At what age did you begin to drink regularly? How often have you consumed alcohol over the past year (or year prior to arrest)? How long have you had that drinking pattern? What date did you last drink? ________ What alcoholic beverage do you usually drink? _________ How many? _____ How often do you drink to intoxication? 13 Questionnaire 2.0 - 2021 How much money do you spend on alcohol in a week? $ Do you want to stop drinking? Y N What would help you remain alcohol-free? If a treatment program is necessary for you at this time, what is your treatment plan? _________________________________________________________ _________ Longest period of sobriety to date? ______Why did you relapse? _________ ___ Please describe your history of substance use, even if you tried a substance only one time DRUG TYPE AGE OF 1ST (Daily, Weekly, etc) LAST USE (mm/dd/yy) Marijuana/hashish Methamphetamine Cocaine/crack Heroin/methadone Hallucinogens – LSD: PCP: Mushrooms: Peyote: Other: Ecstasy/MDMA/Molly ABUSED Prescription meds “Love”/Bath Salts What is your drug of choice? ________________________ When/what did the height of your use look like? _____________________________________________________ 14 Questionnaire 2.0 - 2021 If you have used via IV, when/what and for how long? ___________________________ How much money do you spend on drug use in a week? $______ Have you ever sold or helped arrange the sale of drugs? Y N Have you ever traded or bartered for drugs? Y N Explain: Are you ready to stop using? Y N Why or why not? What would help you remain drug-free? If a treatment program is necessary at this time, what is your treatment plan? __________________________________________________________ _________ Longest period of sobriety to date? ________ Why did you relapse? In the last year: Has your use of alcohol and/or drugs contributed to problems with: law enforcement? Y N - How: _________________________________________ family/relationships? Y N - How: school or employment? Y N - How: ______________________________________ your health? Y N - How: _______________________________________________ Has your tolerance of alcohol and/or drugs increased? Y N Have you ever: tried to stop and been unable? Y N - Explain: ______________________________ ___________________________________________________ suffered withdrawals? Y N - Describe: _____________________________ overdosed? - When/Explain: _____________________________________________ 15 Questionnaire 2.0 - 2021 SUBSTANCE TREATMENT Identify any counseling or treatment program you have participated in to address alcohol/drug abuse issues Treatment Provider & City/State Dates or Outpatient (to include incarceration or Did you complete? How long did you maintain sobriety after program? EDUCATION Please provide a copy of your high school/college diploma, GED/HSE, or vocational certificate Name of junior high or high school you last attended: City and State: ________________________________ Last grade COMPLETED: Did you graduate from high school? Y N Date you last attended (best estimate): If you did not graduate, why? _____________________________________________ Did you participate in any special education classes or have you been diagnosed with a learning disability? Y N Please explain: Please identify any problems reading, writing, speaking, or understanding English: Do you speak, read, or write any other language? Were you ever SUSPENDED or EXPELLED from school Y N - why? 16 Questionnaire 2.0 - 2021 Did you obtain your GED or HSE? When and where? ________________ Name of last college or vocational school attended: ____ When did you attend? ______________ List any degree or certification(s): Do you have any education goals for the future? MILITARY Please bring a copy of your DD 214 form If male, did you register with Selective Service when you turned 18? Y N Any military service: Entry Date Branch of Service Highest Rank Identify any service in a recognized war zone: Please explain if you ever received any military disciplinary action: Date and type of discharge: __________________________ Please explain if you did not receive an Honorable Discharge: ________________________________________ ______________________________________________________________________ CURRENT EMPLOYMENT Please provide copies of your last two pay stubs Employer Name & Address: ________________________________________________ Business telephone #: _____________________ Position: ____________________ Wage: Date you started this job: How many hours do you work per week? Is this a seasonal job? Y N If yes, how do you gain money to pay your bills in the “off” season? ______________ Is your employer aware of this charge? Y N Are you paid “under the table?” Y N 17 Questionnaire 2.0 - 2021 Your supervisor’s name: How would your supervisor describe you as a worker? On a scale of 1 to 10 (10 high) how would you rate your current job satisfaction? Why not higher? Why not lower? Do you get along with your boss? _______________ Co-workers? _________________ PAST EMPLOYMENT How many jobs have you held in the past two years? _________ Any seasonal work in the past year? _________________________________________ List jobs held in the last two years if you have not maintained the same job End Date Hours Phone: If retired or disabled are you collecting Social Security? Y N Income: $_________ If disabled, reason you are receiving benefits: Start month/year of (circle one) RETIREMENT or DISABILITY: ____________________ Are you able to work part time? Y / N If yes, what type of work do you do or what would you like to do? _______________________________________________________ During the past year, how many months total have you been employed? ____________ What is the longest period you have held the same job? Name of business? ______________________________________________________________________ 18 Questionnaire 2.0 - 2021 Have you ever been fired? Y N If yes, please explain: _______________________________________________________ What are your job skills/experience: Do you have any problems holding steady employment? Y N If yes, please explain: ____________________________________________________ ______________________________________________________________________ If incarcerated, are you an inmate worker, and if so what was you start date? And your job(s) ? LEISURE/RECREATION What do you enjoy doing in your spare time? ______________________________________________________ How often have you participated in these activities over the past year? Identify any sports clubs, church, or other community groups you are involved with, and state how often you have participated in the past year? ______________________________________________________________________ FINANCIAL In the last year, have you received government/charity (welfare, cash assistance, food stamps, housing assistance or unemployment benefits)? Y N Please explain the type and circumstances: Which of these benefits are you currently receiving? Please explain any bankruptcy year/circumstances: How promptly do you pay your bills: NEVER ON TIME PAY WHEN I CAN USUALLY ON TIME ALWAYS ON TIME 19 Questionnaire 2.0 - 2021 How sure are you that you can make enough (legally) to meet costs of living and court- ordered fines/fees/restitution and/or supervision costs on a consistent basis? UNABLE UNSURE MILDLY CONFIDENT CONFIDENT Would you benefit from additional financial education or assistance with budget development? Y N RESIDENCE HISTORY Mailing Address (if different than physical): If incarcerated, how satisfied are you with your housing assignment? VERY UNSATISFIED UNSATISFIED SATISFIED VERY SATISFIED Reason for this rating? What is your plan for residence (include address if known) upon release from custody? If not incarcerated, how would you describe your current living situation? COUCH-SURFING TEMPORARY OKAY DON’T PLAN TO MOVE How many times have you moved in the past year (temporary moves, motels, etc)? _____ Are you currently homeless? Y N If yes, for how long and why? If homeless, where do you usually sleep at night? Who are the other occupants (including children) in the home? Please list name, age, and relationship to you: ___________________________________________________ Describe your satisfaction with your current community housing? __________________ Do you get along with the people you live with? Y N If no, please explain: Do you plan to move from your current residence? Y N If yes, why, when, and to where? How would you rate the level of illegal activity in your current neighborhood? NONE VERY LITTLE SOME A LOT 20 Questionnaire 2.0 - 2021 List all weapons kept in your home, vehicle, or kept for you by friends or family members? (i.e. rifles, handguns, BB guns, hunting knives, swords, blow darts, martial arts weapons, etc): What other city/states/countries have you lived in? ______________________________________________________________________ In the year prior to committing this crime, did you live outside of Idaho? Y N If yes where did you live and how long did you live there? VALUES What is important to you in your life? What are your goals moving forward? ________________________________________ ______________________________________________________________________ Comments to the Court (will be typed word-for-word in your report): THE INFORMATION WHICH I HAVE FURNISHED IN THIS PRESENTENCE INVESTIGATION PERSONAL HISTORY QUESTIONNAIRE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. _______________________________________________ Printed Name Defendant’s Signature Date IF SOMEONE ELSE FILLS OUT THIS QUESTIONNAIRE FOR YOU, THEN THAT PERSON MUST ALSO SIGN AND DATE. _______________________________________________ _________________ Printed Name Signature Date