Parole & Probation Monthly Report
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2LANE COUNTY PAROLE & PROBATION
PH: (541) 682-3040 / FAX: (541) 682-3035
75 West 5
Avenue, Eugene OR 97401
th
Client Name: ___________________________________________________
DOB: ___/____/___
PO: _______________________
Other Names Used: ______________________________________________
Date: ______________________
(Please truthfully answer all questions in reference to the last 30 days)
:
Current Living Situation
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What type of housing are you currently living in?
House/Trailer
Apartment
Hotel/ Motel
Shelter/Emergency Housing/Homeless
__________________________________________________________________________________
Physical Address:
Street Numbers/Name
Apartment/Space #
City/State/Zip
________________________________________________________________________________
Mailing (if different):
Street Numbers/Name
Apartment/Space #
City/State/Zip
_________________________
: _________________
: _______________
Vehicle Make/Model:
Vehicle Color
Vehicle Plates
: (____) _____________________
(_____) ____________________________________
My Contact Phone
Message Phone
: ________________________________
Email: ____________________________________ Names of all people living at residence
:
Employment/Education and Financial
SSI/Disability/Retired
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Did you work full time, part time, or just occasionally?
Full time
Part time
Occasional
What is your schedule? ______________________________________________________________________________________________
Employer:_________________________________________________________________________________________________________
What is Your Job: __________________________________________________________________________________________________
Wage: _____________________________ Supervisor/Advisor: _____________________________________________________________
Phone: (____) _______________________ My favorite job would be:_________________________________________________________
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Do you go to school full time, part time, or just occasionally?
Full time
Part time
Occasional
What is your schedule: _____________________________________________________________________________________________
School:__________________________________________________________________________________ Hours/week: ______________
What are you studying: ______________________________________________________________________________________________
:
Attitude/Orientation
What happened during the past 30 days that went well? How did it make you feel?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What happened during the past 30 days that didn’t go well and how did you deal with it?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What affect has your attitude and behavior had on your friends or family?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
:
Friends/Associates
Who is your closest friend? _________________________________________________ Time spent together this month? _______________
Describe a healthy activity you participated in this month with a friend or associate:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Describe a risky situation you may have been in with your friends and how you handled it:
__________________________________________________________________________________________________________________
:
Family/Relations
Who is your significant other? _________________________________________________________________________________________
In the past 30 days my family member/significant other and I had fun doing:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Describe any problems/arguments you have had with a family member/significant other during the past 30 days?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
(Over)
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