Legal History Sample Clauses

Legal History. Past Criminal Charges:  Yes No If yes, specify: History of Assault/Violence:  Yes Current Legal Involvement:  Yes No No If yes, specify: If yes, specify: (Charges, probation order, upcoming court ) (See criteria for admission) Are you coming for treatment because of a court order?  Yes

Legal History. Have you ever been arrested? Yes or No (circle one) If yes, please explain: Have you ever been incarcerated? Yes or No (circle one) If yes, please explain: Are problems with the law currently a concern for you? Yes or No (circle one) If yes, please explain:

Legal History. (Arrests, incarcerations, parole/probation, lawsuits, child custody, court order for therapy): Substance Use: Previous and Current Drug Type (Circle those that apply) Age of First Use Age of Last Use Amount Frequency Results of Use Prescription Drugs- other than as prescribed Over the Counter Drugs- not as directed Nicotine- cigarettes, dip Alcohol Marijuana/Hashish-other hallucinogens Barbiturates- other sedatives hypnotics Benzodiazapine- other tranquilizers Cocaine/Crack- other stimulants Methamphetamine- other amphetamine Opiates- heroin, non-rx-methadon, morphine Inhalants Phencyclidine (PCP) Other/Drug Unknown Family history of substance use: In Case of an Emergency: In the unlikely event of an emergency I, ___________________________, give permission to Xxxxxxxx Xxxxxxx to contact _____________________________________ by phone at___________________ . Signature Date Signature Date CLIENT’S COPY TO KEEP Xxxxxxxx Xxxxxxx, LMFT Airpark Dr., Chattanooga, TN 37421 Phone: (000) 000-0000 THERAPY AGREEMENT/INFORMED CONSENT WITH POLICIES AND PROCEDURES Please read and sign in the places requested, indicating your understanding of my fees and office procedures. I’ll be happy to answer any questions.

Legal History. Has the child been involved with the court currently or in the past? Date(s): Describe: Current Probation? Yes No Probation Officer: Phone #:

Legal History. List all current and/or past involvement with the juvenile system, including referrals, adjudications, informal probations or dismissals. YEAR OFFENSE PLACE Are you currently on probation/diversion? YES NO If “yes” please explain why? NAME OF PROBATION OFFICER: COUNTY

Legal History. List all current and/or past involvement with the juvenile system, including referrals, adjudications, informal probations or dismissals. YEAR OFFENSE PLACE Are you currently on probation/diversion? YES NO If “yes” please explain why? NAME OF PROBATION OFFICER: COUNTY MISC. INFORMATION ARE YOU CURRENTLY TAKING ANY MEDICATIONS? YES NO WILL YOU NEED TO TAKE THEM AT SCHOOL? YES NO If “yes”, please describe the medications (include how many milligrams and how often taken) and the reasons for use: ARE YOU CURRENTLY WORKING? YES NO EMPLOYER NAME: PHONE NUMBER: SUPERVISOR’S NAME: TOTAL HOURS PER WEEK Written questions (MANDATORY- Student must fill out): ALL applicants must answer the following questions. Please answer each question in at least 2 sentences or more. You may use another piece of paper if necessary. The screening committee will look at these questions when deciding your acceptance to the YES House School.

Legal History. List all current and/or past involvement with the juvenile system, including referrals, adjudications, informal probations or dismissals. YEAR OFFENSE PLACE Are you currently on probation/diversion? _____YES _____NO If “yes” please explain why? __________ __________________________________________________________________________________________________________________________________________________________________________________________ NAME OF PROBATION OFFICER: __________________________________ COUNTY _________________ MISC. INFORMATION ARE YOU CURRENTLY TAKING ANY MEDICATIONS? ____ YES ____ NO WILL YOU NEED TO TAKE THEM AT SCHOOL? ____ YES ____ NO If “yes”, please describe the medications (include how many milligrams and how often taken) and the reasons for use: _______________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ARE YOU CURRENTLY WORKING? ____ YES ____ NO EMPLOYER NAME: _______________________ PHONE NUMBER: _________________ SUPERVISOR’S NAME: ______________________ TOTAL HOURS PER WEEK _______ Written questions (MANDATORY- Student must fill out): ALL applicants must answer the following questions. Please answer each question in at least 2 sentences or more. You may use another piece of paper if necessary. The screening committee will look at these questions when deciding your acceptance to the YES House School. Why should we accept you into our school? ______________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Where do you see yourself in 90 days? ___________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________...