Psi Report Long Form

Topics: Substance abuse, Mental disorder, Mental illness Pages: 24 (2054 words) Published: February 9, 2012
Presentence Investigation Form

Fill out completely and accurately. If you are unsure of an answer, estimate to the best of your knowledge and note that it is an estimate. All information will be verified and any discrepancies will be noted to the Court. Defendant Information

Full (Legal) Name: ____________________________________________________________


Alias or Nickname: ________________________________________________________________

Current Address: _____________________________________Phone:_______________________



Permanent Address: ____________________________________________________________

(if different from above)

Date of Birth:____ /_____/_____ Social Security No.______________________________________

City & State of Birth_______________________________________________________




ID Marks (inc. tattoos, scars) ________________________________________________________



US Citizen_____Y______N Alien Status:______________________________________________

Driver’s License No. ____________________State of Issue________License Status_____________

Contact Persons






Please describe what you did to be arrested for this offense. This is your version of the offense and your statements will be directly quoted in this Pre-Sentence Report and will be submitted to the Court. You may also make any statements you wish in regard to your feelings about the offense and any other information that you feel is important in relation to the offense. (You may use another sheet of paper if necessary)

Criminal Orientation

Age of first conviction?___________________________________________________ Ever convicted as an adult under the age of 18?_______________________________

Ever been placed in the Indiana Boys or Girls School?__________________________

Do you have a prior Felony conviction in Indiana?______________________________

Have you been arrested in another state besides Indiana or a county besides Montgomery?_________If yes, where?______________________________________ ____________________________________________________________


Ever charged with a Battery or another violent offense?_________________________

Ever charged with Escape as an Adult or Runaway as a Juvenile?_________________

Ever had a jail or prison write-up for discipline?________________________________

If yes, for what? And what was your sanction?_________________________________

Ever had a Felony reduced to a Misdemeanor at Sentencing?____________________

At the time of the present offense were you on Probation?_______________________ On Parole?____________________________________________________________

Have you been on Probation before?__________where?________________________

Have you been on Parole before?___________from what prison?_________________

Have you had Probation or Parole Violations?_________________________________

Have you had your Probation or Parole Revoked?_____________________________

Is your driver’s license suspended?_________Has it been before?_________________

Ever been a member of a juvenile or adult gang?______________________________ If yes, how long?________________Name of gang____________________________

Do you have relatives or close friends currently in the...
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