Sixth Judicial District

Department of Correctional Services

An Iowa with No More Victims

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Personal Information

Name *

First

Last

Date of Birth

Gender

Height

Weight

Hair Color

Eye Color

Race

Ethnic Origin

Hispanic
Non-Hispanic

Citizenship Status

Number of Children

Contact Information

Address

Address Line 1

Address Line 2

City

State

Zip Code

How long have you lived at this address?

Email *

Primary Phone

Secondary Phone

Educational Information

Highest level of Completion

High School Name/City and State

Highest Grade Complete

College Name/City and State

Were you ever in any special education classes in school?

Yes
No

Do you have any learning disabilities?

Yes
No

Military Service

Military Branch

Never Served
Air Force
Army
Coast Guard
Marine Corps
National Guard
Navy
Reserve
Other than U.S.

Start Date

End Date

Are you a Veteran?

Yes
No

Military Occupation

Discharge Type

Honorable
General
Other Than Honorable
Bad Conduct
Dishonorable
Other

If “Other”, please explain

Employment Information

Employment Status

Full-Time
Part-Time
Seasonal
Spot Job
Unemployed
Retired
Disabliiy
Student

Employer

Employer Phone

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Start Date

Hourly Wage $

Annual Income $

Other Pay $

Work Schedule (Days/Times)

Victim Information

Victim's Name

Victim's Age

Relationship with Victim

Victim's Phone

Treatment Information

Do you have a mental health diagnosis?

Yes
No

If Yes, please list Primary Diagnosis

Are you currently under the care of a psychiatrist, psychologist or counselor?

Yes
No

Are you prescribed medication?

Yes
No

If yes, are you currently taking medication as prescribed?

Yes
No

Have you ever received substance abuse treatment?

Yes
No

Did you complete?

Yes
No

Emergency Contact

Name

Relationship

Phone

Sixth Judicial District of Iowa * Department of Correctional Services
Benton County * Iowa County * Johnson County * Jones County * Linn County * Tama County