JUVENILE INTAKE FORM
ID#: ____________________ DISPOSITION: ____________ CASE: _____________________ DATE: ____/____/____
JUVENILE INFORMATION
Juvenile Full Name: ________________________________________________ SSN: _______-_______-_______ DOB: _____/_____/_______
Mailing Address: ________________________________________ City: __________________ State: _______________ Zip: _________________
Physical Address: ________________________________________ City: __________________ State: _______________ Zip: _________________
Home Phone: __________________________ Cell: ___________________ Work: _____________________ Employer: ______________________
Race: ____________ Sex: ____ Height: ____________ Weight: ___________ Build: ______________ Hair: _____________ Eyes: _____________
Scars, Marks, Tattoos, Birth Marks: _______________________________________________ Allergies: __________________________________
School attending: ________________________________________ Grade: _______ Nickname: __________________________ Age: ___________
GUARDIAN/CUSTODIAN INFORMATION
Natural Mother: ______________________________________________ SSN: _____-_____-_____ DOB: ____/____/______ Race: _________
Home Phone: __________________ Cell: __________________ Work: __________________ Employer: __________________________________
Mailing Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Physical Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Natural Father: _______________________________________________ SSN: _____-_____-_____ DOB: ____/____/______ Race: _________
Home Phone: __________________ Cell: __________________ Work: __________________ Employer: __________________________________
Mailing Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Physical Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Step/Mother: _________________________________________________ SSN: _____-_____-_____ DOB: ____/____/______ Race: _________
Home Phone: __________________ Cell: __________________ Work: __________________ Employer: __________________________________
Mailing Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Physical Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Step/Father: __________________________________________________ SSN: _____-_____-_____ DOB: ____/____/______ Race: _________
Home Phone: __________________ Cell: __________________ Work: __________________ Employer: __________________________________
Mailing Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Physical Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Other Guardian/Custodian: ___________________________________ SSN: _____-_____-_____ DOB: ____/____/______ Race: _________
Home Phone: __________________ Cell: __________________ Work: __________________ Employer: __________________________________
Mailing Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Physical Address: ________________________________________________ City: __________________ State: ______________ Zip: __________
Siblings Currently Living In the Home:
Name: _____________________________________________ DOB: ____/____/______ SSN: ______-____-______ Male or Female
Name: _____________________________________________ DOB: ____/____/______ SSN: ______-____-______ Male or Female
Name: _____________________________________________ DOB: ____/____/______ SSN: ______-____-______ Male or Female
Name: _____________________________________________ DOB: ____/____/______ SSN: ______-____-______ Male or Female
BACK FOR OFFICE STAFF ONLY
Involvement with ANY Juvenile Office: YES NO If yes, explain: ________________________________________________________________
_____________________________________________________________________________________________________________________
FAMILY HISTORY
Parental Substance Abuse: YES NO Explain: _________________________________________________________________________________
Physical Abuse/Neglect: YES NO Explain: ___________________________________________________________________________________
Sexual Abuse: YES NO Explain: ___________________________________________________________________________________________
Mental Illness or Health Handicaps in Family: YES NO Explain: ________________________________________________________________
Parental Incarceration: YES NO Explain: ___________________________________________________________________________________
REFERRING AGENCY INFORMATION
Referring Agency/Person: ________________________________________ Date/Time Committed: _______/______/_______ ______:______
Address Where Committed: _______________________________________________ City: ___________________ State: ____ Zip: _________
Complainant/Victim: ____________________________________________ Allegations: ______________________________________________
Complainant/Victim Address: _____________________________________________ City: ___________________ State: ____ Zip: _________
JUVENILE INFORMATION
Juvenile Substance Abuse: YES NO Explain: _________________________________________________________________________________
Juvenile Abuse: SEXUAL PHYSICAL EMOTIONAL MENTAL NO Explain: _____________________________________________________
Juvenile Mental Illness, Learning Disorder or Health Handicaps: YES NO Explain: ________________________________________________
Out of Home Placement: YES NO Explain: __________________________________________________________________________________
Prior Referrals: YES NO Explain: __________________________________________________________________________________________
Employed: FULL PART NO Children: YES #______ NO Grades: As Bs Cs Ds Fs Passing Failing School Attendance: GOOD POOR
Insurance: Private Medicaid Restitution: $_____________________
Detention: Date In: _____/_____/_____ Date Out: _____/_____/_____ Counseling: ____________________________ CSW Hours: __________
Drug Related: YES NO Drug Type: ___________________________ Alcohol Related: YES NO Alcohol Type: ___________________________
NOTES/OTHER INFORMATION
___________________________________
Deputy Juvenile Officer
