Detention Assessment Screening Instrument
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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
DETENTION ASSESSMENT SCREENING INSTRUMENT
Date Screened / Time:
I.
IDENTIFYING DATA
Last
First
MI
DOB
Number and Street/City/State/Zip
Telephone Number
Gender
Race
Ethnicity
Student at: (Name of school and address)
Employed by: (Name of company and address)
Parent / Guardian
Non-Custodial Parent
Number and Street/City/State/Zip
Number and Street/City/State/Zip
Telephone Number(s)
Telephone Number(s)
Alleged Present Offense(s) (
)
Specify level and class / Felony, Misdemeanor A, B, etc.
N/A
Regarding the juvenile, did the arresting / investigating officer observe evidence of:
alcohol abuse?
Yes
No
drug abuse?
Yes
No
Did the arresting officer note any signs or symptoms of suicidal ideations or actions?
Yes
No
Parent / Guardian Interviewed
Yes
No
1. Face to Face
2. Telephone
3. Unable to Contact
4. Message Left With Whom:
Name
Relationship
Law Enforcement Agency
Officer's Name and ID or Badge No. (officer who completes this form)
(JPPO)
District Office Contacted?
Yes
No
NHJB-2581-DF (03/09/2009)
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