Fairfield County Common Pleas Court

Pre-Sentence Investigation Packet

In order to prepare its pre-sentence investigation, the Fairfield County Community Control Department is requesting information about you, your case, and your background.

Please fill out this questionnaire as completely and honestly as possible. The information you provide will be verified to determine if it is truthful and accurate.

If necessary, a Pre-Sentence Investigator will review this form with you (in the presence of your attorney or with your attorney's consent) and may ask additional questions or request additional information at a later date prior to sentencing.

You may return this form in any of the following ways:

Deliver in-person to:
Pre-Sentence Investigator Keshia Sanders
224 E. Main Street, 1st Floor
Lancaster, OH 43130
E-mail to: keshia.sanders@fairfieldcountyohio.gov
angel.sanderson@fairfieldcountyohio.gov
Mail to:
Fairfield County Common Pleas Court
ATTN: CC Department
224 E. Main Street, 1st Floor
Lancaster, OH 43130

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Authorization for Release of Information

I hereby give my consent to an investigation of my background and current circumstances conducted by Community Control Officers of the Fairfield County Common Pleas Court. In addition, I hereby authorize the release of any/all records, including, but not limited to, records held by Juvenile Court (including any sealed records), Children's Services, Department of Job and Family Services, The Recovery Center, Lancaster Recovery Services, Mid-Ohio Counseling Services, New Horizons Mental Health Services, Mended Reeds Services, Integrated Services for Behavioral Health, Ohio Guidestone, Phoenix Center, Adams Recovery Center, Appalachian Behavioral Healthcare, Fairfield County Child Support Enforcement Agency, The Social Security Administration, and the following additional agencies:

Full Name

Date of Birth

SSN Format: XXX-XX-XXXX

Additional agencies authorized for release of records:

Purpose or need for disclosure: (1) to provide information to the Court and Community Control Department for the purpose of obtaining information that will be useful in determining whether I am a repeat offender and/or eligible for community control, and/or (2) to provide information on program participation, evaluation of social, medical, psychological problems, and reports on evaluations, findings, prognosis, and recommendations for treatment. This is a reciprocal release allowing the Fairfield County Common Pleas Court Community Control Department to release information to the above-mentioned parties.

By consenting to this investigation (for Community Control Application Only) and authorizing release of records, I do not admit guilt or waive any rights. I fully understand, however, that any report prepared as a result of this investigation will be submitted to the Court. This consent to disclose may be revoked by me at any time except to the extent that action has been taken in reliance thereon. This consent (unless expressly revoked earlier) expires upon the completion of client/patient's term of probation on:

Expiration Date (probation completion)

I hereby state that I have read and fully understand the above.

Signature of Client or Person Authorized to Consent

Witness

Date Signed

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Please answer all questions completely and accurately.

General Information

Full Name

Age

Date of Birth

SSN Format: XXX-XX-XXXX

E-Mail Address

Phone

Address

I (check one):

Own my residence Rent my residence Stay at this residence for free

How long have you lived at this address?

Who lives with you? Include name and relation:

Place of Birth

U.S. Citizen?

Yes No

Race

Gender

Height

Weight

Hair Color

Eye Color

Highest Level of Education Completed

School(s) Attended

Criminal History

List all previous felony convictions

Year	County	Offense(s)

List any misdemeanor offenses for which you've been convicted in the past 10 years (include past OVIs, but not other traffic cases)

Year	County	Offense(s)

List any open or active cases currently pending against you

Year	County	Offense(s)

Have you ever been affiliated with a gang?

Yes No

If yes, list type of affiliation:

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Family

Marital Status

Significant Other's Name

Age

Address

Phone

Occupation

Is your Significant Other currently on Bond, Probation, or APA Supervision?

Yes No

If so, with what court/department and for what offense?

Does your Significant Other have any past felony criminal convictions?

Yes No

If so, please complete the information about those convictions:

Year	County	Offense(s)

Are any of your immediate family members (siblings, parents, children) currently on bond, probation, APA supervision, in prison, or in jail?

Yes No

If so, complete the information below:

Name	Relation to You	Reason on probation / in jail

Do you have any children?

Yes No

If so, please complete the information below:

Name	Age	Does child reside with you?
		Yes No
		Yes No
		Yes No

Military

Have you ever been involved with the military?

Yes No

If so, complete the information below:

Branch of Service	Dates of Service	Type of Discharge	Rank at Discharge

Employment

Current Employment Status

Current Employer

Type of Work

Job Title

Time with Employer

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Past Employment History – Last 5 Years

Employer	Job Title	Dates Employed	Reason for Leaving

Medical, Psychiatric, & Psychological History

Current Physical Health Self-Assessment

Great Good Fair Poor

Current Mental Health Self-Assessment

Great Good Fair Poor

Have you ever attempted suicide?

Yes No

If so, complete the information below:

Date of Attempt	Method of Attempt

Medical History – List any significant physical or mental health conditions that affect your daily life:

Medical Condition	Date Condition Began

Medication Information – List all medications you currently take:

Name of Medication	Dosage	Valid Prescription?	Prescribing Doctor
		Yes No
		Yes No
		Yes No

Substance Abuse Information

Do you believe you currently have a substance abuse problem?

Yes No

Has a friend or family member ever asked you to get help with substance abuse?

Yes No

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Substance Use History

Substance	Age of First Use	Using at Time of Alleged Offense?
Substance	Alcohol		Yes No
Marijuana		Yes No
Ecstasy		Yes No
LSD		Yes No
Cocaine (Powder)		Yes No
Cocaine (Crack)		Yes No
Methamphetamine		Yes No
Heroin		Yes No
Inhalants		Yes No
Bath Salts		Yes No
K2		Yes No
Fentanyl		Yes No
Kratom		Yes No
Tramadol		Yes No
Amphetamine		Yes No
Opiates		Yes No
Suboxone		Yes No
Other:		Yes No

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Counseling & Treatment History

Have you ever engaged in counseling/treatment (including Medication-Assisted Treatment services) for substance abuse or mental health reasons?

Yes No

If so, complete the information below:

Name of Agency	Type of Treatment	Dates Attended	Level of Care	Results / Reason for Discharge

Future Expectations

In your opinion, why should the Court order you to be placed on Community Control (Probation) instead of imposing a jail or prison sentence?

What specific areas of your life need attention or help that you believe the Court or Community Control (Probation) Department can provide to you?

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ONLY ANSWER THE QUESTION BELOW IF YOU HAVE PLED GUILTY OR BEEN FOUND GUILTY IN YOUR CASE.
If you have not yet pled guilty or been found guilty in your case, do NOT answer the last question.

Description of Offense

Describe, in your own words, your crime or offense. Include any reason you had for doing what you did and how you feel about it.