Form Dhs 1277 - Service Questionnaire Page 8
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10Additional information
Do you have a clean driving record?
Yes
No
If no, please explain:
Have you ever been arrested or convicted of a felony or a misdemeanor?
Yes
No
If yes, please explain:
Are you currently on supervision of any type?
Yes
No
If yes, and you are actively supervised, please list name and phone number of
probation/parole officer:
Name:
Phone:
Counselor notes:
Do you have any other current legal issues/problems? (specify):
Do you have any history of substance use or abuse?
Yes
No If yes, please explain:
Could you pass a drug test?
Yes
No If no, please explain:
Counselor notes:
Education information
Are you a high school graduate or do you have a GED?
Yes
No
If not, what is the highest grade you completed:
Were you in special education classes while in school?
Yes
No
Did you have an Individualized Education Program (IEP)?
Yes
No
Do you have a 504 Plan?
Yes
No
Were you a participant in the youth in transition program?
Yes
No
If yes, to any of the above questions, please indicate school name, city and state:
School name
City
State
Page 8 of 10
DHS 1277 (10/2016)
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Parent category: Legal