Fillable ECJPO Intake Packet 2020 (County of Erie)

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ECJPO Intake Packet 2020 (County of Erie)

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Juvenile Probation Intake Packet
This form is to be completed by the PARENT/GUARDIAN. It is important that the
ALL sections are completed as ACCURATELY as possible. Please fill out, print and
bring this form to your child’s scheduled appointment or you can email the
completed form to juvintake@eriecountypa.gov All information provided will be
kept confidential and will help Erie County Juvenile Probation process the case in a
timely fashion.
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JUVENILE INFORMATION
Today’s Date:
Juvenile’s Name: _ D.O.B.:
(Last) (First) (Middle) (Suffix)
Address:
(Street and Apt. #) (City) (State) (Zip Code) (Township)
When did you move there (Date):
Email: _
Is this Public Housing?
U
S Citizen
Yes No
Y
es No
Phone Home:
Cell:
Erie County Resident?
Interpreter Needed?
Yes No
Yes No
Juvenile’s Social Security Number: Language Spoken: _
Juvenile’s Alias or Nickname: _
Is OCY Involved? Yes No Current Caseworker: _
Current Judge Involved: _
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G
ender: Male _ Female _
Height:
Weight:
Eye Color: _
Hair Color:
Body Build:
Large Frame
Large Muscular Frame
Medium Frame
Medium Muscular Frame
Muscular
Small Frame
Small Muscular Frame
Complexion:
Acne
Black
Dark
Fair skin
Light Ski _
Medium
Olive
Pale
Pock-Marked
Ruddy
Severe Acne
Swarthy
Tanned
Race:
National Origin:
Alaska Native or American Indian
Asian
Black
Native Hawaiian or Pacific Islander
Unknown
White
Anglo
African American
Iraqi
Spanish
Central American
Taiwanese
Middle Eastern
Chinese
Southeast Asian
Italian
French
Russian
Polish
Hispanic
Unknown
Scars/Tattoos/Identifying Marks/Piercings? Yes No (If YES, describe & list location)
JUVENILE PHYSICAL DESCRIPTION
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JUVENILE PHYSICAL HEALTH HISTORY
Physical Health Issues – Past & Present: Date: _
Date: _
Medications & Reason Taken: _
Prescribing Doctor:
Drug & Alcohol Use: _
JUVENILE’S MENTAL HEALTH HISTORY
Diagnosis: Date of Diagnosis: _
Diagnosing Psychologist or Psychiatrist:
Diagnosis: Date of Diagnosis: _
Diagnosing Psychologist or Psychiatrist:
Medications:
In-Patient Hospitalizations:
Past Agency Involvement:
Date: _
Date: _
Current Mental Health Services & Agency:
FAMILY DOCTOR
Doctor or Facility Name:
Care Provided: Medical Prescription Vision
Address:
(Street and Apt. #) (City) (State) (Zip Code)
Phone: Fax:
DENTIST
Doctor or Facility Name:
Address:
(Street and Apt. #) (City) (State) (Zip Code)
Phone: Fax:
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Over $10,000 and under $15,000 _
Over $15,000 and under $20,000 _
Over $20,000 and under $30,000 _
Over $30,000 and under $50,000 _
Monthly Social Security Income:
____________
Monthly Welfare Income:
____________
Current Number in Family:
STRUCTURE INFORMATION (FAMILY STATUS)
Biological Parent Status
Juvenile’s Current Living Situation
Check all that apply
Married
_
Year
Both Biological Parents
Biological Mother
Divorced
_
Biological Father
Separated
_
Relative
One Parent Deceased
_
Father & Step Mother
Both Parents Deceased
_
Mother & Step Father
Parents Never Married
_
Shared Custody Arrangement
Court Ordered Custody
Other
_
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Adoptive Parent(s)
Other
Please Explain:
Are th
ere any pets in the home? ___YES ___No If Yes, Describe:___________________
Are there any weapons in the home? ___Yes ___No
*If Ye
s:
What kind? ___________________________________________________________
Where are they located? ________________________________________________
Are th
ey secured? _____________________________________________________
HOUSEHOLD INCOME INFORMATION
Under $10,000 per year
_
Over $50,000
_
FINANCIAL AND FAMILY INFORMATION
JUVENILE’S EMPLOYMENT
Employed:
Yes
No
Employer:
____________
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JUVENILE’S INSURANCE INFORMATION
Company:
Insurance Type (Check All That Apply) Dental Medical Prescription Vision
Policy Number: Insurance Number:
Group Number: _ Responsible Party: _
Company:
Insurance Type (Check All That Apply) Dental Medical Prescription Vision
Policy Number: Insurance Number:
Group Number: _ Responsible Party: _
PRIMARY INSURANCE
SECONDARY INSURANCE
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Please check one: _Biological Father _Adoptive Father
Name: D.O.B.:
(Last) (First) (Middle) (Suffix)
Social Security Number: _- _- _ Language(s) Spoken: _
Address:
(Street and Apt. #) (City)
(State)
(Zip Code) (Township)
Date Moved There: _
Phone Contact
Home:
Email:
Employer:
Cell: Occupation:
Work: _
List All Others Living in this Home:
Name
DOB Relationship to Client
Are
any, or have any of these people been involved with Adult or Juvenile Probation?
Yes No
If YES, what is Probation Officer’s Name?
PARENT OR GUARDIAN INFORMATION
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Please check one: _ Biological Mother _Adoptive Mother
Name: Maiden Name: _
(Last) (First) (Middle) (Suffix)
Social Security Number: _- _- _ Language(s) Spoken: D.O.B.:
Address:
(Street and Apt. #) (City) (State) (Zip Code) (Township)
Date Moved There: _
Phone Contact
Home:
Email:
Employer:
Cell:
Occupation:
Work:
List all Others Living in this Home:
Name
DOB Relationship to Client
Are any, or have any of these people been involved with Adult or Juvenile Probation?
Yes No
If YES, what is Probation Officer’s Name?
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Significant Others
Step-Parent Parent’s Paramour
Legal Guardian Foster Parent
Relative Other (Explain)
Name: _ D.O.B.:
(Last) (First) (Middle) (Suffix)
Social Security Number: _- _- _ Language(s) Spoken: _
Address:
(Street and Apt. #) (City) (State) (Zip Code) (Township)
Date Moved There: _
Phone Contact
Home:
Cell:
Work: _
Email:
Employer:
Occupation:
List All Others Living in this Home:
Name
DOB Relationship to Client
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JUVENILE’S SCHOOL INFORMATION
Current Status: In School Out of School Classes Regular/Special
Home School: Current School As of Today:
Vo-Tech: Yes No
Date Started at Current School: Ending Date: _
Starting Grade at Current School: _ Current Grade Level:
GPA: _
If Out of School:
Last School Attended:
Last Day and Year Attended: Final Grade Completed: _
Comments (i.e. discipline problems grades, attendance, or tardy issues, etc.):
Does Juvenile have a Driver’s License? ___Yes ___No
If yes, issuing State & License Number:______________________ Date Issued: ___________
Learner’s Permit Number: _______________
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**This Page for Probation Office Use Only**
CASE NOTES
1)
Previous Handlings (i.e., DJ Incident Reports, Diversion)
2)
Other Agency Involvement – or – Legal Involvement
(i.e., OCY/District Judges/Counselors, etc.)
3)
Significant Others (i.e., associates, peers, relatives, etc.)
4)
Explanation of Offense, Admit or Deny
Offense # (Admit/Deny) Explanation:
Offense # _ (Admit/Deny) Explanation:
Offense # (Admit/Deny) Explanation:
5)
Restitution:
6)
Victim Impact Statement: Yes No
JP # _ Photo # _ Assigned PO: _
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Recommendation: _
Releases:
Photo Taken Yes No
Urine Sample Collected Yes No
Change of Address Form Yes No
Individuals Present at Intake:
DOCUMENT VERIFICATION
Birth Certificate:
Yes
No
Comment(s):
Social Security Card:
Yes
No
Comment(s):
_
Medical Card:
Yes
No
Comment(s):
Citizenship/Naturalization:
Yes
No
Comment(s):
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ECJPO Intake Packet 2020 (County of Erie)

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Completed 5 August 2020

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