Probation Detainer Form Home Page Date this form was filled out. MM DD YYYY Client Name * First Name Last Name PP Number Client Phone Number (###) ### #### Alternative Phone Numbers Client Email Date of Birth MM DD YYYY Current Age Race Gender Male Female Other Gender if Other Height Weight Client Address Address 1 Address 2 City State/Province Zip/Postal Code Country Can you return to this address? Yes No DV/SAO Can you receive mail there? Yes No Home for: Housing Type Rent Own Temporally PHA Family or Friend Other Rent Living with: Housing Notes or Alternative Address Address suitable for House Arrest? PHA properties are ineligible. All others must have permission from landlord or owner. Primary Alterative Both Neither Children CAU Conflict Yes No Born in Philadelphia? Yes No Place of Birth If not if Phialdelphia How long have you lived in Philadelphia? Immigration Referral? Yes No Identification ID No ID Valid Drivers License You you have a Passport Yes No Support Network Family, Friends, Neighbors, Co-workers, Case Manager, Sponsor, Religious or Spiritual Leader Supporter 1 First Name Last Name Relationship Phone (###) ### #### Email They may Help with: Attend Hearing Bail Supporter 2 First Name Last Name Relationship Phone (###) ### #### Email They may Help with: Attend Hearing Bail Supporter 3 First Name Last Name Relationship Phone (###) ### #### Email They may Help with: Attend Hearing Bail Support Notes Military Service Yes No Veteran Years in Military Military Branch Military Rank Military Discharge Honorable Dishonorable Medical Other Military Notes Total Bail $ Amount Client can afford $ Custody Not in Custody CF DC PHCG RCF Other Other Custody How long have you been in custody? How long have you been absconding? Arrest Date MM DD YYYY Day of the Week Arrest Time Hour Minute Second AM PM Search Warrant Yes No Unsure Other Arrest Warrant Yes No Unsure Other Active Warrant(s) Now? Yes No Unsure Other Surrender Yes No Other Arrest Notes Charges Detainer Yes No Violation Type Direct Technical Both Violation Notes Hearing Type Gagnon 1 Gagnon 2 Safe Surrender Supervision Type Probation Parole Both How long have you been on supervision? All NCDs/VOPs and Room Numbers Juvenile Records Judge Name(s) Report Type and Frequency By Phone Weekly Monthly Other Other: Is your P.O. aware of D&A, Mental Health, or Medical Concerns? Yes No Unsure or Not Completely Aware Yet Has your P.O. offered help for your challenges? Urine or Drug Tests Clean Dirty Improving Relationship With P.O. Challenges Successes P.O. Notes Employed? Yes No Employer: Job Title Location Hours per Week Weekly Pay $ Employed Since: Can you Return? Yes No Unsure Confirm with: Other Income Yes No Other Income Amount $ Other Income Source Family SSI SSDI Other Income Notes Seeking Employment? Benefits SNAP Medical Assistance Medicare Medicaid Other SNAP Amount $ Education: Did not Finish High School High School Diploma GED Vocational or Tech Some College College Degree Other IEP/ Special Education? Yes No Currently Enrolled? Yes No School: Interested in Continuing Education? Yes No Education Notes Community Involvement Volunteer Mentor Religious or Spiritual Group Activities with Youth Support Group Other Community Involvement Notes Medical Insurance Yes No Mental Health Physical Health Substance Use Yes, Currently No, Never Past Use Substance Use Notes MAT Prescribed Interested Past Treatment? Current Treatment ROI Yes No Interested in Treatment? Yes No In the past 6 months, have you lost Employment Housing A Loved One Other Loss: Are you now at Risk of Losing Employment Housing Custody Other At Risk: What is this case preventing you from doing? Paying Rent Working Childcare Caring for a Dependent Accessing Treatment Other This case is Preventing: What do you want the Judge to Know? What are 3 Things you Hope to Accomplish in the Next 6 Months? General Notes and Details Thank you! ⭐Above~All~Odds ⭐Above~All~Odds ⭐Above~All~Odds
