TCI DRCS INTAKE FORM

INTAKE FORM

Please answer each question as honestly and completely as you can. If you are not sure about a question, ask a Probation Officer for help. Your answers will help us understand how to support you during your probation or parole.

Section 1: Personal History

Officer Name

Officer Email

Date:

First:

LAST:

Date OF Birth:

Age

Gender

Nationality Nationality

Address:

Phone

My Primary Language is:

Are there any parts of the island you avoid or cannot go to because of personal safety concerns?

If yes, list:

Emergency Contact Name:

Emergency Contact Phone

Section 2: Offense History

Any Previous Convictions/Arrests?

Current Offense:

Magistrate/Judge:

Section 3: Family, Education, & Living Situation

Marital Status

Do you have any children?

If yes, how many?

Current Living Arrangement:

Highest Level of Education Completed:

Employment Status:

Employer/ School Name:

Job Title:

Section 4: Health & Substance Use

Do you have any current physical health problems?

If yes, explain:

Are you currently taking any medication?

If yes, list:

Are you currently experiencing any emotional or psychological distress?

Have you ever been diagnosed with a mental health condition?

If yes, what diagnosis:

Have you ever used drugs?

If yes, list: (Hold down the Ctrl Key for multiple selection)

Do you currently drink alcohol?

If yes, how often:

Have you ever had a problem with drugs or alcohol?

Section 5: Goals, Motivation & How You Spend Your Time

Are you involved in any hobbies, sports, or community activities?

If yes: please list:

On average, how many hours per week do you spend on positive, structured activities?

On a scale of 1 to 10, how motivated are you to make positive changes in your life?

Pick one or more things you’d like to change: (Hold down the Ctrl Key for multiple selection)

Section 6: Client Acknowledgment

I understand that the information I have provided in this form will help the Department of Rehabilitation and Community Supervision (DRCS) to better understand my background, needs, and goals. This information will be used to support the development of a case plan that can assist me in making positive changes and successfully completing my probation or parole.

I confirm that the information I provided is true and complete to the best of my knowledge.

Probation Officer

Client Signature

Clear