1 JUVENILE IMMEDIATE INTERVENTION APPLICATION FORM

JUVENILE IMMEDIATE INTERVENTION APPLICATION FORM
DISTRICT ATTORNEY’S OFFICE (DAO), SHAWNEE COUNTY, KANSAS
FOR PARENT TO COMPLETE
PLEASE FILL OUT COMPLETELY USING INK OR TYPE.
CHILD’S NAME:___________________________________________
NOTE: In order for the DAO to make an appropriate finding in your child’s case, it is imperative that you answer
every question. The application process is considered ongoing. Any subsequent law enforcement contact or other
change in circumstances occurring prior to placement in the program must be reported immediately.
HAS YOUR CHILD EVER HAD ANY PRIOR ADJUDICATION, CONVICTION, DIVERSION, OR
INFORMAL ADJUSTMENT IN SHAWNEE COUNTY OR ANY OTHER COURT (MUNICIPAL, STATE,
YOUTH/TEEN OR FEDERAL)? This includes offenses that were previously expunged. ( ) Yes ( ) No
If yes, please list:
DATE
CHARGE
COURT
OUTCOME
DOES YOUR CHILD HAVE ANY ADDITIONAL CHARGES PENDING IN SHAWNEE COUNTY OR ANY
OTHER COURT?
( ) Yes
( ) No
If yes, please list:
DATE
CHARGE
COURT
NEXT COURT HEARING
BIOGRAPHICAL INFORMATION
CHILD’S NAME:____________________________________________AKA:________________________________
ADDRESS:___________________________________CITY________________________STATE_____ZIP________
PHONE:__________________________SCHOOL:______________________________SSN:___________________
DOB:____________AGE:_____SEX:______HEIGHT:________WEIGHT:_________HAIR:________EYE:_______
RACE:
( ) Caucasian
( ) African-American
( ) Native American
( ) Hispanic
( ) Asian
COUNTRY OF BIRTH:___________________STATE OF BIRTH:___________CITY:________________________
FATHER:_________________________________
STEP-FATHER:______________________________
ADDRESS:________________________________
ADDRESS:___________________________________
CITY/STATE:______________________________
CITY/STATE:_________________________________
EMPLOYER:_______________PHONE:________
EMPLOYER:_______________PHONE:___________
HOME PHONE:____________________________
HOME PHONE:_______________________________
CELL PHONE:_____________________________
CELL PHONE:________________________________
DOB:__________ EDUCATION:______________
DOB:__________ EDUCATION:_________________
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MOTHER:________________________________
STEP-MOTHER:_____________________________
ADDRESS:________________________________
ADDRESS:___________________________________
CITY/STATE:______________________________
CITY/STATE:_________________________________
EMPLOYER:_______________PHONE:________
EMPLOYER:_______________PHONE:___________
HOME PHONE:____________________________
HOME PHONE:_______________________________
CELL PHONE:_____________________________
CELL PHONE:________________________________
DOB:__________ EDUCATION:______________
DOB:__________ EDUCATION:_________________
SOCIAL HISTORY INFORMATION
1. PARENTS:
( ) Married
( ) Separated ( ) Divorced ( ) Widowed ( ) Other:________________________
2. DOES THE CHILD RESIDE WITH SOMEONE OTHER THAN THE PARENTS?
( ) Yes
( ) No
IF YES, PLEASE STATE NAME AND RELATIONSHIP TO THE CHILD:
NAME:
RELATIONSHIP TO CHILD:
__________________________________________
____________________________________________
3. SIBLINGS:
NAME:
_________________________________
_________________________________
_________________________________
_________________________________
AGE:
_______________
_______________
_______________
_______________
LOCATION:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
4. LIST ANY OTHER PEOPLE LIVING IN THE HOME.
NAME:
AGE:
_________________________________
_______________
_________________________________
_______________
_________________________________
_______________
_________________________________
_______________
RELATIONSHIP:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
5. DESCRIBE CHILD’S RELATIONSHIP WITH FATHER/STEP-FATHER:_______________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6. DESCRIBE CHILD’S RELATIONSHIP WITH MOTHER/STEP-MOTHER:______________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. DESCRIBE CHILD’S RELATIONSHIP WITH SIBLINGS:___________________________________________
_____________________________________________________________________________________________
8. HAVE OTHER MEMBERS OF YOUR FAMILY HAD ANY CONTACT WITH POLICE AND/OR COURT?
IF YES, EXPLAIN.____________________________________________________________________________
9. ARE THERE ANY DIFFICULTIES WITH YOUR CHILD IN THE HOME?_____________________________
_____________________________________________________________________________________________
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10. DESCRIBE YOUR CHILD’S OVERALL ATTITUDE:_______________________________________________
_____________________________________________________________________________________________
11. DESCRIBE YOUR CHILD’S PAST RUNAWAY EXPERIENCES, IF ANY:_____________________________
_____________________________________________________________________________________________
12. DESCRIBE YOUR CHILD’S PEER RELATIONSHIPS:______________________________________________
_____________________________________________________________________________________________
EDUCATION
1. SCHOOL:___________________________________________________ GRADE LEVEL:__________________
IF CURRENT GRADES ARE NOT AVAILABLE, LIST THE MOST RECENT SUBJECTS AND GRADES
FROM PREVIOUS QUARTER OR SCHOOL YEAR.
SUBJECT
LETTER GRADE
1._____________________________________________________
_____________
2._____________________________________________________
_____________
3._____________________________________________________
_____________
4._____________________________________________________
_____________
5._____________________________________________________
_____________
6._____________________________________________________
_____________
7._____________________________________________________
_____________
2. HOW DOES YOUR CHILD’S SCHOOL PERFORMANCE COMPARE WITH HIS CAPABILITIES?________
_____________________________________________________________________________________________
3. WHAT SPECIAL LEARNING PROGRAMS HAS YOURCHILD PARTICIPATED IN, IF ANY:____________
_____________________________________________________________________________________________
4. LIST ANY SUSPENSIONS/EXPULSIONS YOUR CHILD HAS HAD IN SCHOOL.
DATE
IN OR OUT
# OF DAYS
REASON
OF SCHOOL
______________
______________
______________
_______________________________________
______________
______________
______________
_______________________________________
______________
______________
______________
_______________________________________
5. LIST YOUR CHILDS’ ORGANIZED ACTIVITES IN SCHOOL OR THE COMMUNITY:_________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
EMPLOYMENT
1. LIST YOUR CHILD’S EMPLOYMENT HISTORY:
DATES
EMPLOYER
RATE OF PAY
_____TO______ ______________________ _____________
_____TO______ ______________________ _____________
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REASON FOR LEAVING
_______________________________________
_______________________________________
2. DESCRIBE YOUR CHILD’S WORK HABITS AND ATTITUDES:_____________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PHYSICAL AND EMOTIONAL HEALTH
1. DESCRIBE YOUR CHILD’S OVERALL PHYSICAL HEALTH:______________________________________
2. IS YOUR CHILD TAKING ANY MEDICATION?_________ IF YES, PLEASE LIST:_____________________
_____________________________________________________________________________________________
HAS YOUR CHILD BEEN INVOLVED IN COUNSELING, THERAPY, OR INPATIENT TREATMENT?______
IF YES, PLEASE LIST:
THERAPIST
DATE(S)
REASON
OUTCOME
______________________
_____________
__________________________
_____________________
______________________
_____________
__________________________
_____________________
4. HAS YOUR CHILD OR ANY FAMILY MEMBER MADE ANY SUICIDE THREATS OR GESTURES?
_____________________________________________________________________________________________
5. DESCRIBE FREQUENCY OF ALCOHOL AND OTHER DRUGS USED BY ANY MEMBER OF THE
FAMILY:__________________________________________________________________
TO MY KNOWLEDGE THE INFORMATION PROVIDED IS CORRECT AND ACCURATE. I
UNDERSTAND THAT PROVIDING FALSE STATEMENTS OR WITH HOLDING MATERIAL
INFORMATION CAN BE THE BASIS OF THE COURT SETTING ASIDE THE IMMEDIATE
INTERVENTION AND REINSTATING PROSECUTION ON THE COMPLAINT. ADDITIONAL POLICE
CONTACT OR CHANGES IN SOCIAL CIRCUMSTANCES OCCURING AFTER THE SUBMISSION OF
THIS APPLICATION MAY RESULT IN A REVOCATION PROCEEDING.
This application cannot be processed unless it is signed and dated by the respondent and at leat one
parent(guardian)
________________________________________________
Respondent (Juvenile)
__________________________
Date
________________________________________________
Parent/Legal Guardian
__________________________
Date
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