SAMPLE JUVENILE RAPPORT-BUILDING CONTACT Sheetdesigned to Help the Officer Get All The

ANYTOWN POLICE DEPARTMENT

123 Main Street

Anytown, USA 070476

SAMPLE JUVENILE RAPPORT-BUILDING CONTACT SHEETDesigned to help the officer get all the information needed to learn the subject’s background, educational level and information to enable effective rapport-building with the juvenile.

Suggestions: Complete this form with as much detail as possible. Initial Blank Lines to indicate they were intentionally left blank OR Mark N/A if non-applicable.

Purpose: To determine as much information possible to assist in investigation, Miranda Comprehension and Rapport Building

Incident #: ______Incident Date: ______Incident Time:______

Incident Type: ______

Incident Address: ______

Multiple Juveniles: Yes: ______No: ______

Referral Source (if applicable) Name: ______

Agency/ Address: ______Phone: ______

Care Giver __ School __ Law Enforcement ___ Mental Health __ Fire Service __

Parent __ EMS ___ Result of incident___ Other ______

Juvenile Information

Last Name: ______First Name: ______Middle Name: ______

Date of Birth: ______Age: ____ Place of Birth: ______

Sex: Male __ Female__ Transgender __ Unknown __

Race: White __ Asian __ African American __ Native American __ Hispanic __ Other _____

Home Address: ______

Home Phone: ______Cell Phone: ______

Soc. Sec. # ______Other Identifying # (ie; Alien Registration) ______

Mother Name: ______Alive ___ Deceased ____ In Picture ___

Father Name: ______Alive ___ Deceased ____ In Picture ___

Adult #1 Residing With the Child:

Last Name: ______First Name: ______Middle Name: ______

Date of Birth: ______Age: ____ Place of Birth: ______

Sex: Male __ Female__ Transgender __ Unknown __

Race: White __ Asian __ African American __ Native American __ Hispanic __ Other _____

Home Address: ______

Home Phone:______Cell Phone: ______Work Phone:______

Employed: Yes __ No: If yes where? ______

Marital Status: Married __ Separated __ Divorced __ Remarried ___ Widowed __

Relation to Juvenile: Natural __ Step __ Adoptive __ Foster __ Grandparent __ Other ______

Adult #2 Residing With the Child:

Last Name: ______First Name: ______Middle Name: ______

Date of Birth: ______Age: ____ Place of Birth: ______

Sex: Male __ Female__ Transgender __ Unknown __

Race: White __ Asian __ African American __ Native American __ Hispanic __ Other _____

Home Address: ______

Home Phone:______Cell Phone: ______Work Phone:______

Employed: Yes __ No: If yes where? ______

Marital Status: Married __ Separated __ Divorced __ Remarried ___ Widowed __

Relation to Juvenile: Natural __ Step __ Adoptive __ Foster __ Grandparent __ Other ______

Others Residing With the Child

Name: ______Relationship: ______

Employment and Community Activity:

Currently Employed: Yes __ No __ If Yes Where? ______

Career Interests: ______

Volunteer Involvement: ______

Church Involvement: ______

Community Involvement: ______

School Education:

Last Grade Placement: ______Grades Completed: ______

School Currently Attending ______

Does the minor have an Individual Education Plan (IEP)? Yes __ No __

Are services (tutoring/speech/specialized classes/counseling) provided? Yes __ No __

Describe ______

Current grades (A/B, Passing/Failing) ______

Attendance: Attending Regularly ___ # Absences per week _____ # Tardy per week _____

School Suspensions Yes __ No __ If Yes When ______How Many ______

School Expulsion Yes __ No __ If Yes When ______

Medical:

ADD/ ADHD Diagnosed: Yes __ No __

Doctor: ______Last Visit: ______Why: ______

Current Medications: ______

History of Mental Health Issues: Yes __ No __ If Yes Explain ______

Substance Abuse: Yes __ No __ If Yes Explain ______

Trauma / Crisis / Loss:

Has there been any significant trauma, crisis or loss in the juvenile’s life (eg; loss of family member or friend, witness to a violent crime, sudden homelessness, separation from a close relative)? Yes __ No __

If Yes Explain ______

Friends:

Close Friends: Yes __ No __ If Yes: How Many? _____ Who? ______

Activities With Friends: ______

Any Friend Currently Involved With Court System: Yes __ No __ If Yes Why? ______

Social Media:

Email (school and personal): ______

Twitter: ______

Facebook: ______

Other (specify): ______

Music preference: ______

Associations/ Groups:

Sports (specify): ______

School clubs/groups/activities (ie: recycling club, school play, etc.): ______

Gang Affiliation: No__ Yes __ If Yes Who? ______

Appearance/ Dress Style: Goth __ Emo __ Skater __ Jock __ Preppy __ Nerd __ Other ______

Other Associations/Groups (include any self-identification by juvenile) ______

Legal History:

Does the juvenile have an attorney? Yes __ No __ If Yes Who? ______

Has the juvenile ever been charged with any previous delinquent or criminal acts? Yes __ No __

If Yes Explain: ______

Is the juvenile on Probation? Yes __ No __ If Yes What For? ______

Who is/was the Probation Officer? ______

Other Information: ______