PSI Interview Sample

DEPARTMENT OF CORRECTIONAL SERVICES

PSI/LSI-R Interview Guide – Community Based

Interviewer: _________________________________ Date: ______/_______/_______

Name: ______________________________________ Alias (es) ______________________________

Address: _________________________________________________ How long: ___________

Date of Birth: ____________ Age: _____ SSN: __________________ Birthplace: ________________

Phone #: ______________________ Driver’s License #: ______________________

Sex: ________ Race: ___________ Eyes: ________ Hair: __________ Height: ______ Weight: _____

Citizenship: __________________ Legal Resident Alien/Green Card: _______

Visitor/Student Visa: __________ Illegal Alien: _________________

Distinguishing Marks: __________________________________________________________________

Current Offense (s): ____________________________________________________________________

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Co-defendant (s): ______________________________________________________________________

Attorney (Privately retained or Court Appointed): ____________________________________________

YOUR VERSION OF THE CURRENT CHARGES:__________________________________________

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CRIMINAL HISTORY (must be verified)

Any other charges pending in any other criminal court? Yes No What & Where: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you had any prior adult convictions? Yes No

If yes, how many? _______________

What happened?

What are you currently under supervision for (include all counts)?

What happened?

How old were you the first time you were in trouble with the law? ___________

What happened?

What were the consequences?

Have you ever done any jail or prison time? Yes No

Have you ever escaped or attempted to escape from a youth or adult correctional facility? Yes No

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If incarcerated or in the residential facility, what were you written up for and what were the consequences?

Have you ever had probation, parole or work release violations? Yes No

Have you ever had your probation, parole or work release revoked? Yes NoIf yes, why?

Have you ever been assaultive or used other forms of violence? Yes NoIf yes, specify what did you actually do?

EMPLOYMENT

Current Employment: Full time Part time Unemployed Retired Student Disabled Welfare

Current Employer’s Name: ____________________________________________

Address: __________________________________________

__________________________________________

Phone: ____________________________________________

Your Job Title: _____________________________________Pay Rate: _______________________Start date: ______________________Supervisor’s Name: _________________________________

Current Employer’s Name: ____________________________________________

Address: __________________________________________

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Phone: ____________________________________________

Your Job Title: _____________________________________Pay Rate: _______________________Start date: ______________________Supervisor’s Name: _________________________________

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Past Employer’s Name: ____________________________________________

Address: __________________________________________

Phone: ____________________________________________Your Job Title: _____________________________________Pay Rate: _______________________From/To: ______________________Reason for termination: _________________________________


Address: __________________________________________

Phone: ____________________________________________Your Job Title: _____________________________________Pay Rate: _______________________From/To: ______________________Reason for termination: _________________________________


Address: __________________________________________

Phone: ____________________________________________

Your Job Title: _____________________________________Pay Rate: _______________________From/To: ______________________Reason for termination: _________________________________

In the last 12 months, how many months were you employed full-time? _________

What is the longest full-time job you have ever held? ___________________________________Where? ___________________________________________________________________How Long? ________________________________________________________________

Have you ever been fired? Yes NoHave your legal charges ever caused you to leave a job? Yes NoHave you ever walked off the job without giving notice? Yes NoHave you ever just quit going to a job? Yes No

Tell me about your job.

What do you like best and least about it?

How would you rate your performance?

If I were to see you a year from now, would you still be working there? Yes No

Describe your relationship with your co-workers.

Do they know you’re under supervision? Yes No

What do they think of that?

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Do you spend time outside of work with them? Yes No

Do you eat lunch/take breaks with them? Yes No

Are your co-workers good influences for you? Yes No

Are they people you should/would like to hang around with? Yes No

Describe your relationship with your boss:

Do you feel your boss does a good job? Yes No

MILITARY HISTORY

Branch: ________________________ Start Date: _________________ End Date: _______________

Discharge Type: ______________________________________ Rank at Discharge: ________________

Comments:

EDUCATION

Last school attended: _______________________________________________ Highest grade: ________

Graduation date: ____________________ Quit date: __________________ Quit reason:

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Grade Point Average: ___________________ Place/Date GED: _________________________________

Vocational training: ______________________________________________________________________

Are you interested in continuing your education: _______________________________________________

Have you ever been suspended or expelled (including in-school suspensions) from any type of school? Yes No

How would you rate your participation/progress in school?

Describe your relationship with other students:

Describe your relationship with your teachers:

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FINANCIAL

Current source of income (amounts): ________________________________________________________

Spouse/partner’s income: ______________________ Household income last 12 months: ______________

Bank: _________________________ Checking balance: ____________ Savings balance: _____________

Other income sources:

Real Estate: _________________________ Stocks/bonds/securities: ________________________

Insurance: ___________________________ Welfare: ____________________________________

Soc. Sec: ____________________________ Unemployment: ______________________________

Pension: ____________________________ Child Support: _______________________________

Property values:

Real Estate: _______________ Vehicles: ___________________________________

Debts (mortgage, rent, loans, credit cards, etc.):

Company Amount Date Payment Balance Reason for loan

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Dependents: ________________________________________________________________________

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In the past year, have you experienced any financial problems? Yes No

What is your take-home pay? _________________________

Are you worried about having enough money to pay debts/meet needs? Yes No

Does anyone complain about how you spend your money? Yes No

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Do you owe back child support? Yes NoWhat other debts do you have? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How do you manage your money? ______________________________________________________Do you have a plan for paying you debts and obligations? Yes NoAre your wages being garnished? Yes No

During the past year, have you received any type of financial assistance such as food stamps, FIP, WIC, Title XIX, unemployment, disability, workman’s compensation, etc., or does anyone in your household receive any of these from which you benefit? Yes No

FAMILY/MARITAL

Marital Status: Single Married Divorced Widowed Separated Common-law Engaged

Significant Other’s Name: __________________________ Age: ______ Occupation: _____________

Address: ________________________________________________________________________

Phone: ________________________

Marriage Date/Place: ______________________________________________________________

Divorce Date/Place: _______________________________________________________________

Criminal Record: _________________________________________________________________

Substance Abuse History: __________________________________________________________

Mental Health History: ____________________________________________________________

Children Reside With: ___________________________ Child Support: __________________

Name: ____________________ Age: _____ Address: _________________________Name: ___________________ Age: _____ Address: _________________________Name: ___________________ Age: _____ Address: _________________________Name: ___________________ Age: _____ Address: _________________________

Prior Marriages Name: __________________________ Age: ______ Occupation: _____________Address: ________________________________________________________________________ Phone: _________________________Marriage Date/Place: ______________________________________________________________ Divorce Date/Place: _______________________________________________________________Criminal record: __________________________________________________________________Substance Abuse History: __________________________________________________________Mental Health History: ____________________________________________________________

Prior Marriages Name: __________________________ Age: ______ Occupation: _____________Address: ________________________________________________________________________ Phone: _________________________Marriage Date/Place: ______________________________________________________________ Divorce Date/Place: _______________________________________________________________Criminal record: __________________________________________________________________Substance Abuse History: __________________________________________________________Mental Health History: ____________________________________________________________

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Are you currently in a relationship? Yes No

If no, have you been in one during the last year? Yes No

If you are single, how do you feel about being single?

Why did your relationship end?

Is he/she under supervision? Yes No

Tell me about that relationship, (How long you’ve been together. What you like most about your relationship. How you feel about the relationship)

When you disagree, what happens?

What areas of disagreement are there?

How have your legal problems affected the relationship?

What did your partner say about your offense and the consequences?

Has a fight ever gotten physical? Yes No

Have you or your partner ever been unfaithful? Yes No

Do you have any children? Yes No

If yes, how many? ________________

Have you ever argued about child rearing? Yes No

How do you discipline your children? _________________________________________________

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Do you have any fears about hurting your children? Yes No

FAMILY of ORIGIN

Father: Natural Adopted Step Grandparent

Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________

Occupation: ______________________________________ Health: ________________________

Quality of Relationship: ____________________________ Frequency of Contact: ____________

Criminal Record: _________________________________________________________________



Married? _______________________ Divorced? ___________________________________

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Father: Natural Adopted Step Grandparent

Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________




Mother: Natural Adopted Step Grandparent

Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________




Mother: Natural Adopted Step Grandparent

Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________




Siblings: Natural Adopted Step

Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________




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Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________





Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________





Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________





Name: ________________________ Age: _____________ Phone: ________________________

Address: ________________________________________________________________________



Criminal Record: _________________________________________________________________




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How would you describe your relationship with your parents and/or stepparents?

How often do you have contact with them?

In what ways has your relationship with your parents changed due to your legal difficulties? What did

they say about your offense and the consequences?

Do any of your parents have a history of substance abuse or violent behavior?

Tell me about your relationship with other relatives. How often do you have a contact with them?

Siblings? ________________________________________________________________________

Grandparents? ____________________________________________________________________

Aunts/Uncles/Cousins? ____________________________________________________________

Other? __________________________________________________________________________

What have they said to you about your offense and its consequences?

Has anyone in your family (spouse or close relative) been involved in criminal behavior? Yes No

Explain:

ACCOMMODATIONS

If currently incarcerated, address upon release: _____________________________________________

Who will you live with: _______________________________________________________________

Prior Residences (past 10 years) Dates Lived With

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How do you like the place you live? ______________________________________________________

Do you rent or own your residence? ___________ How long have you lived there? _______________

Do you plan to move? Yes No

If so, why and when? _________________________________________________________________

Not including incarceration, where have you lived in the past year?

Describe your neighborhood (i.e., quiet, middle class, high crime area, frequent raids, gang activity, etc.

Would you be able to buy drugs and/or buy or sell something stolen within your neighborhood?)

LEISURE/RECREATION

Have you been active in any organizations or clubs during the past year? Yes No

If yes, describe:

How do you spend your free time? Describe a typical day:

When you do these, are you using?

Any hobbies? When was the last time you did this?

COMPANIONS

Tell me about the people you hang around with:

What types of things do you do with your friends?

Do you use together? Yes No

How does your usage compare with you friends’ usage?

Do you know anyone who has been in trouble with the law or involved in breaking the law?Yes No

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Have any of your friends been in trouble with the law or involved in things that would get them in trouble with the law? Yes No

How many people do you know who have been in trouble with the law and have never engaged in criminal activity?

How many of your friend have never been in trouble with the law and have never been engaged in criminal behavior?

What did these friends say about your offense?

ALCOHOL/DRUG PROBLEMS

Have you ever had an alcohol problem? Yes NoHistory: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever had a drug problem? Yes NoHistory: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When was the last time you drank any alcohol? (Date) _______________________________________

When was the last time you used any drugs? (Date) _________________________________________

What drugs did/do you use and what method? (shoot, snort, smoke):

Within the last year, has your use of drugs or alcohol contributed to your past law violations? (i.e., probation violations, alcohol/drug convictions, theft to support habit, etc.) Yes No

Within the last year, has your family complained to you about your drinking/drug use? (i.e., has a relationship ended due to your use, have you been kicked out of home, has usage caused problems in family relationships, etc.) Yes No

Within the last year, have you had problems in school or work in military due to use of alcohol drugs? (i.e., been late due to hangover, failed drug testing, fired due to being intoxicated at work, financial problems, etc.) Yes No

Within the last year, have you had any medical problems due to drug or alcohol use? (i.e., hepatitis, sleep loss, memory loss, weight loss, dental, stomach, STDs, suicide, accidents or injuries)

Yes No

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Do you drink until you pass out? Yes NoDo you ever drink or take drugs to avoid a hangover? Yes NoDo you drink when you first get up in the morning? Yes NoDo you ever experience blackouts? Yes NoHave you ever attempted to limit your usage? Yes NoHave you used more or longer than intended? Yes NoRecent overdose? Yes NoAny IV use? Yes NoCravings/Decreased/increased tolerance? Yes NoMuscle aches/Tremors/Shakes/Withdrawal/Hallucinations? Yes NoHave you made previous attempts to quit?Do you have difficulty remaining abstinent?What is the longest you have ever gone without using alcohol and/or drugs?______________________

Treatment Provider Dates Completed?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EMOTIONAL/PERSONAL/MENTAL HEALTH

Describe how you feel emotionally on a daily basis:

Do you ever have trouble eating? Yes NoSleeping? Yes NoConcentrating? Yes NoHave you experienced any depression lately? Yes NoWere you a victim of any type of abuse? Yes No

Explain:

How is it affecting you now?

Do you have any concerns about your emotional stability? Yes NoHave you been considering psychiatric consultation? Yes NoHave you been considering voluntary admission to a psychiatric facility? Yes NoDo you think committal to a psychiatric facility may be necessary? Yes NoDo you think a lot about committing suicide? Yes NoDo uncontrollable urges or ideas bother you? Yes No

Have you had any counseling or mental health treatment (to include sex offender treatment but not including educational programs) in the past? Yes No

Have you been diagnosed with any mental health issues? (i.e., depression, borderline personality, antisocial, bipolar, etc). Yes No

Have you ever been placed on medications? Yes NoIf yes, what?

In the past year, have you been in any kind of counseling or treatment? (substance abuse, sex offender treatment counts as well). Yes No

If yes, where?

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If any of the following is present, score this item as “yes.”Learning disabilities? Yes NoLow level of intellectual functioning? Yes NoExcessive fears? Yes NoNegative attitude towards self or depression? Yes NoHostility, anger, aggression or potential for aggression? Yes NoDifficulty with impulse control? Yes NoPoor interpersonal skills? Yes NoLack of confidence in self? Yes NoLack of contact with reality or delusions/hallucinations? Yes NoInability to experience shame/guilt or disregard for feelings of others? Yes NoCriminal acts which appear irrational? Yes NoPersonality disorders? Yes NoSexual deviancy? Yes NoMental illness? Yes NoOther Yes No

Treatment Provider Dates Completed? ___________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PHYSICAL HEALTHDescription: ______________________________________ Occurrence Date: ____________________Medication: _________________________________________________________________________Comments: _________________________________________________________________________

Description: ______________________________________ Occurrence Date: ____________________Medication: _________________________________________________________________________Comments: _________________________________________________________________________

ATTITUDES/ORIENTATIONWhat is the first thing that comes to mind when you think about the trouble that you have been in?

In your opinion, what are the most significant reasons for the trouble you have been in?

Who was affected by your actions and how were they affected?

What needs to happen to make things right with those you have harmed?

What is your opinion of the law, police and courts?

Is there ever a good reason to break the law?

If you could change any of the current laws, what would you change and why?

What goals have you set for yourself?

Do you feel your sentence was appropriate and fair?

If you were the judge, what sentence would you have given yourself?

Do you think the rules of your probation/parole/work release/RCF are appropriate and fair?

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PSI Interview Sample

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