Community Family Court Application | Pdf Fpdf Doc Docx | Oregon

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Community Family Court Application | Pdf Fpdf Doc Docx | Oregon

Community Family Court Application

This is a Oregon form that can be used for Circuit Court within Local County, Jackson.

Alternate TextLast updated: 10/2/2014

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Community Family Court Application General Information Name: _____________________________ Last DOB: ___/___/_____ Sex: M F Date: __________________ _____________________ First _________________ Middle Primary Language: __________________________ Ethnicity (Caucasian, African American, etc): _____________________ Native American/Alaskan Native Heritage? Marital Status: __________________ Y N Tribe: ________________ Tribal Benefits? Y N Name of significant other: ________________________ Do you ever feel afraid of you current partner? Y N Y N Y N Length of Current Relationship: ____________ Did you serve in the military? Y N VA Eligible? Are you currently homeless or without a stable residence? Current Physical Address : _______________________________ City _____________ State ____ Zip ________ Is this your Primary Address? Y N Type of Residence (apt, rental, etc) ___________ Others in household: ______________________________________ Relationship: __________________ Does anyone in your current residence use medical marijuana or illegal drugs? Y N Mailing (if different): __________________________ City _______________ State ____ Zip_________ E-mail: ___________________________________ Cell Phone: (_____) _____-______ If the message phone is not yours, who owns it? Emergency Contact: Name: _____________________ First Relationship: ____________ Ok to contact? Y N Phone: (______) ______-________ Phone: (_____) _____-_______ Message Phone:(_____) _____-_______ _________________________________________ ___________________ Last ______________ Middle Alternate Contact Number: (______)______-________ Legal Information: Please list every county/state where you've had charges or legal trouble: ____________________________________________________________________________________ Please list states/counties where you believe you may have outstanding warrants: _____________________________________________________________________________ Probation Officer? _______________________________ Treatment Orientation Application Page 1 of 5 11/15/07 American LegalNet, Inc. Attorney? ___________________________________ DHS ­ Child Welfare case worker ____________________________________ Financial Information Do you owe Child Support? Do you owe money to other courts or counties? Are/will your wages be Garnished? Y Y Y N N N If so, how much? __________________ If so, how much? ___________________ Uncertain Why? _____________________________________________ How much per month? ____________ Transportation Do you have reliable Transportation? Current Insurance? Y Y N N Do you have a valid ODL? Y N If suspended, or revoked please list all courts where you have outstanding cases or fines: __________________________________________________________________________________ Education Last Year Completed? ______ High School Grad: College Degree: Y N Y N GED: Y N Some College: Y N Last school attended? ___________________________ Grade: _____ School Contact Name: ______________________ Current School? _________________ Employment Information Are you employed? Y N If no, source of income? _______________ Primary Employment: _________________________ Occupation: _______________________________ Employer Contact Name: _____________________ Employer Contact Number: (_____) ______-_______ Income: ___________ Per: _________ Approximate Hrs per Week: ____ Longest you've kept employment? ___________ Primary Skills/Occupation: _______________________ Are you receiving public assistance (TANF or Food Stamps)? Y N Additional Sources of Income ___________________________________________ Medical/ Mental Health History Medical Do you have current medical insurance? Y N Current Physician: _____________________________ Facility: ______________________________ Last medical appointment or emergency room visit: _________________ Reason: __________________ Treatment Orientation Application Page 2 of 5 11/15/07 American LegalNet, Inc. Pregnant? Y N Significant Other Pregnant? Y Y N N Due Date? ____/____/____ Do you have any chronic or current medical conditions? Please list current medical conditions, including prescribed medication (even if you are not currently taking your medication): ____________________________________________________________________________________ ____________________________________________________________________________________ Mental Health: Have you ever been diagnosed with a mental health condition? Y N Please list current and previous mental health diagnoses: ______________________________________ ____________________________________________________________________________________ Are your currently under the care of a therapist, mental health clinician, or physician for a mental health Y N condition? If so, please provide name/contact information: ____________________________________________ Have you ever been hospitalized due to mental illness? Y N If so, please provide the date, location and reason for your hospitalization(s): ______________________ ____________________________________________________________________________________ Have you ever taken medication for mental illness? Y N Please list all mental health medication you are currently taking: ________________________________ ____________________________________________________________________________________ Please list mental health medications you have been prescribed in the past or are no longer taking: _____ ____________________________________________________________________________________ Substance Abuse History Longest period of total abstinence from all drugs and alcohol since start of use: __________________ Drug Frequency (Daily, 1 x per week, etc) Age Began Using Route (IV, Snort, eat, etc) Date of Last Use Rank (order of preference) Have you attended addiction treatment in the past? Y N If so, please provide the following information for each treatment attempt (you may write on the back of the application, if necessary): Treatment Orientation Application Page 3 of 5 11/15/07 American LegalNet, Inc. Name of treatment center: ____________________ Dates attended: _________________________ Type of treatment (outpatient, inpatient): __________________________ Did you successfully complete treatment? Y N If no, why not? ____________________________ Reason for treatment (court-ordered, personal decision, family intervention): _____________________ Name of treatment cen

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