Court Services Client Report Form

This information may be used to confirm your contact with this office in the event of a future court action. Knowingly providing false information on this form will constitute a violation of your probation/parole

Date

Time

Assigned Officer

Case Number

Client Information

Name

Address

City

State

Zip Code

Phone

E-mail address

Have you moved since you last reported?

Explain why?

Vehicle

Do you own a car?

Make

Model

Year

Tag#

Employment Information

Present employer

Effective Date

Employer Address

Phone Number

Supervisor Name

Type of Work

Does your employer know that you are on probation/parole?

Did you miss any work days last month?

Did you miss any work days last week?

Explain why?

Have you changed jobs since your last report?

Explain why?

Work days off:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Name and address of your closest friend or relative

Have you had any contact with law enforcement since your last report, including any traffic violations?

Explain the incident including date, where, when and why

Any drug/alcohol use since last appointment?

Please indicate what used and when

Are you involved in any type of counseling?

Who provided the counseling and when?

Is there anything that you need to inform your Officer?

Please explain

Do you have a Court payment today?

What is the amount?

Are you making monthly payments as arranged?

Remarks/Requests