Mitigation Questionnaire

Please fill out your responses below

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Section 1: Biographical Overview

Full Legal Name (Required)

Gender

Place of Birth (Required)

How Long at Current Address?

Emergency Contact

Martial Status

Date of Birth (Required)

Ethnicity

Current Address (Required)

Phone Number (Required)

Preferred Language

Number of Children

Section 2: Family Background and Early Development

Parents/Guardians

Mother's Name

Mother's Age (if living)

Mother's Occupation

Are Your Parents Still Together?

Father's Name

Father's Age (if living)

Father's Occupation

Are there any family traditions or values that particularly shaped who you are today?

Siblings

Number of Siblings

Relationship with Siblings (Good/Poor/None)

Birth Order (Oldest, Youngest, Middle)

Early Childhood (0-5 years)

Who Primarily Raised You?

Did You Live With Both Parents?

If no, explain living arrangements.

Any early separations from parents/caregivers?

If yes, explain

Any major illnesses or hospitalizations as a child?

If yes, explain

Middle Childhood (6-12 years)

Describe your neighborhood growing up:

Did You Feel Safe at Home?

Always

Usually

Sometimes

Rarely

Never

Did You feel Safe in Your Neighborhood?

Always

Usually

Sometimes

Rarely

Never

Family Financial situation Growing Up

Excellent

Good

Average

Below Average

Poor

Adolescence (13-18 years)

Biggest Challenges During Teenage Years

Relationship with Parents During Teens

Any Family Conflicts or Problems?

Yes

If Yes, Explain

Section 3: Educational History

Highest Level Education Completed

Did graduate high school?

Yes

GED

If no, what grade did you leave school?

Reason for leaving school early:

Overall Grades in School

Excellent

Good

Average

Below Average

Poor

Any learning disabilities diagnosed?

Yes

If yes, which ones?

Any Special Education Services?

Disciplinary Problems in School?

Yes

If yes, explain

Any Suspensions or Expulsions?

Yes

Favorite Subjects

Least Favorite Subjects

Extracurricular Activities or Sports

Post-Secondary Education

Any college, trade school or vocational training?

Yes

If yes, where?

Did you complete the program?

Yes

If no, why not?

Any professional licenses or certifications?

Yes

If yes, list:

Section 4: Employment History

Current Employment Status

Employed

Unemployed

Disabled

Retired

Student

Current Job Title

How Long Have You Had Your Current Job?

Current Employer

Monthly Income

Employment History (Last 5 Years)

Previous Job 1

Employer

Dates

Position

Reason for Leaving

Previous Job 2

Employer

Dates

Position

Reason for Leaving

Previous Job 3

Employer

Dates

Position

Reason for Leaving

Longest Job Held

Job performance Generally

Excellent

Good

Average

Poor

Any workplace injuries?

Yes

If yes, please explain

Section 5: Military Service History

Have you ever served in military?

Yes

If yes, which branch of service?

Dates of Service

Highest Rank Achieved

Type of Discharge

Honorable

General

Other than Honorable

Bad Conduct

Dishonorable

Combat Deployment

Yes

If yes, where and when?

Combat exposure?

Yes

Any combat-related injuries?

Yes

Any military-related PTSD or mental health issues?

Yes

Currently Receiving VA Benefits?

Yes

VA Disability Rating

Section 6: Head Injury/TBI History

Ever had a serious head injury?

Yes

If yes, when and how?

Lost Consciousness?

Yes

If yes, for how long?

Hospitalized for Brain Injury?

Yes

Any Brain Surgery?

Yes

Any Ongoing Problems from Head Injury?

Yes

If yes, what problems?

Ever Diagnosed with Traumatic Brian Injury (TBI)?

Yes

Any Concussions from Sports, Accidents, Fights?

Yes

If yes, how many?

Section 7

Current Relationships

Martial Status

Single

Married

Divorced

Seperated

Widowed

Partner

Quality of Relationship

Excellent

Good

Fair

Poor

If married/partnered, what is your spouse/partners name?

How Long Have You Been Together?

Any Domestic Violence in Relationship?

Yes

If yes, were you the victim or the perpetrator?

Children

Number of Biological Children

Do You Have Custody of Any Children?

Yes

Do You Have Any Child Support Obligations?

Yes

N/A

Are You Current on Child Support?

Yes

N/A

Ages of Children

Relationship With Children

Excellent

Good

Fair

Poor

None

Support Network

Who Are the Most Important People in Your Life?

Who Would You call in an Emergency?

Are You Active in a Religious Community?

Yes

If Yes, For How Long?

Who Do You Turn to For Help or Advice?

How Many Close Friends Do You Have?

Section 8: Cultural and Spiritual Background

Ethnicity/Race:

How Important is Spirituality to You?

Very

Somewhat

Not Very

Not at All

Any Cultural Traditions Important to You?

Yes

If Yes, Please Describe

Religious or Spiritual Beliefs:

Do You Attend Religious Services?

Regularly

Sometimes

Rarely

Never

Primary Language Spoken at Home

Any Language or Communication Issues?

Yes

Section 9: Immigration Status and Consequences

Country of Birth

If not a U.S. Citizen, type of status

How long in the United States?

Family Members' Immigration Status

Concerns about Deportation?

Yes

U.S. Citizenship Status

U.S. Citizen

Permanent Resident

Visa Holder

Undocumented

Any Prior Immigration Issues?

Yes

If Yes, Explain

Immigration Attorney Contacted?

Yes

Section 10: Mental Health Assesment

Current Mental Health

How Would You Describe Your Mental Health Currently?

Excellent

Good

Fair

Poor

Currently seeing a Therapist or Counselor?

Yes

If Yes, Name and Contact

Currently Taking Any Psychiatric Medications?

Yes

If Yes, List Medications

Mental Health History

Ever Been Diagnosed With a Mental Health Condition?

Yes

If Yes, What Conditions?

Ever Attempted Suicide?

Yes

If yes, when and how?

Ever Had Thoughts of Hurting Yourself?

Yes

Ever Been Hospitalized for Mental Health?

Yes

If yes, where and when?

Family History of Mental Illness?

Yes

If yes, what condition and who?

Trauma History

Ever Experienced a Traumatic Event?

Yes

If Yes, Describe

How Old Were You When it Happened?

Did You Receive Counseling for It?

Yes

Do You Still Have Problems Because of It?

Yes

Depression Screening (PHQ-9)

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Little interest or pleasure in doing things

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

2. Feeling down, depressed or hopeless

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

3. Trouble falling or staying asleep, or sleeping too much

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

4. Feeling tired or having little energy

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

5. Poor appetite or overeating

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

9. Thoughts that you would be better off dead or of hurting yourself in some way

0 - Not at all

1 - Several Days

2 - More Than Half the Days

3 - Nearly Everyday

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Anxiety Screening (GAD-7)

Over the last two weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

2. Not being able to stop or control worrying

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

3. Worrying too much about different things

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

4. Trouble relaxing

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

5. Being so restless that it is hard to sit still

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

6. Becoming easily annoyed or irritable

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

7. Feeling afraid, as if something awful might happen

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

If you checked off any of these problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Substance Use Screening (CRAFFT)

Please answer the following questions with yes or no:

1. Have you ever ridden in a Car driven by someone (including yourself) who was "high" or had been using alcohol or drugs?

Yes

3. Do you ever use alcohol or drugs while you are by yourself (Alone)?

Yes

5. Do your family or Friends ever tell you that you should cut down on your drinking or drug use?

Yes

2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?

Yes

4. Do you ever Forget things you did while using alcohol or drugs?

Yes

6. Have you ever gotten into Trouble while you were using alcohol or drugs?

Yes

PTSD Screening (PC-PTSD-5)

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, physical or sexual assault or abuse, an earthquake or flood, war, seeing someone be killed or seriously injured, or having a loved one die through homicide or suicide.

In the past month, have you...

1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?

Yes

3. Been constantly on guard, watchful, or easily startled?

Yes

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

Yes

2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

Yes

4. Felt numb or detached from people, activities, or your surroundings?

Yes

6. Have you ever gotten into Trouble while you were using alcohol or drugs?

Yes

Audit-C

1. How often did you have a drink containing alcohol in the past year? (Choose one)

Monthly or less

2-4 times a month

2-3 times per week

4 or more times a week

2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? (Choose one)

3 or 4

5 or 6

7 to 9

10 or more

3. How often did you have six or more drinks on one occasion in the past year? (Choose one)

Less than monthly

Monthly

Weekly

Daily or almost daily

Adverse Childhood Experiences (ACE)

Before the age of 18:

1. Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Yes

3. Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Yes

5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Yes

7. Did a parent or adult in your home ever swear at you, insult you, or put you down?

Yes

9. Did you feel that no one in your family loved you or thought you were special?

Yes

2. Did you lose a parent through divorce, abandonment, death, or other reason?

Yes

4. Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Yes

6. Did you live with anyone who went to jail or prison?

Yes

8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Yes

10. Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal inter-course/penetration)?

Yes

Drug Abuse Screening Test (DAST-10)

In the past 12 months:

1. Have you used drugs other than those required for medical reasons?

Yes

3. Are you always able to stop using drugs when you want to? If never use drugs, answer “Yes”

Yes

5. Do you ever feel bad or guilty about your drug use? (If never use drugs, answer “No”)

Yes

7. Have you neglected your family because of your use of drugs?

Yes

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Yes

2. Do you use more than one drug at a time?

Yes

4. Have you ever had blackouts or flashbacks as a result of drug use?

Yes

6. Does your spouse (or parents) ever complain about your involvement with drugs?

Yes

8. Have you engaged in illegal activities in order to obtain drugs?

Yes

10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Yes

Mood Disorder Questionnaire (MDQ)

1.Has there ever been a period of time when you were not your usual self and...

...you got much less sleep than usual and found you didn’t really miss it?

Yes

...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? )?

Yes

...thoughts raced through your head or you couldn’t slow your mind down?

Yes

...you had much more energy than usual?

Yes

...you were much more interested in sex than usual?

Yes

...spending money got you or your family into trouble?

Yes

...you were so irritable that you shouted at people or started fights or arguments? ...you felt much more self-confident than usual? )?

Yes

...you were much more talkative or spoke much faster than usual?

Yes

...you were so easily distracted by things around you that you had trouble concentrating or stay-ing on track?

Yes

...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

Yes

...you did things that were unusual for you or that other people might have thought were exces-sive, foolish, or risky?

Yes

2. If you checked YES to more than one of the above, have several of these ever happened dur-ing the same period of time?

Yes

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?

No Problem

Minor Problem

Moderate Problem

Serious Problem

4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

Yes

5. Has a health professional ever told you that you have manic-depressive illness or bipolar dis-order?

Yes

Section 11: Substance Use History

Current Use

Do You Currently Drink Alcohol?

Yes

If Yes, How Often?

Daily

Weekly

Monthly

Rarely

How Many Drink Per Occasion?

Ever Drink and Drive?

Yes

Do you have any allergies to medications or other substances?

When was your last physical examination?

Do You Currently Use Illegal Drugs?

Yes

If Yes, Which Drugs?

How often do you use drugs?

Substance Use History

Age when you first drank alcohol?

Age when you first used drugs?

What was the first drug you used?

Heaviest Period of Drinking/Drug Use

How long did that last?

Ever tried quitting drinking or using drugs?

Yes

Ever been to treatment for substance abuse?

Yes

If Yes, Where and When?

Ever been to AA, NA or other support groups?

Yes

Family History of Alcoholism or Drug Use?

Yes

If yes, who?

Section 12: Community Connections and Contributions

Volunteer Work or Community Service

Hobbies or interests

Skills or talents

How do others describe you?

Member of any organizations or clubs

Athletic activities or sports

Any awards or recognition received?

What are you most proud of in your life?

Section 13: Economic/Financial Stressors

Current Monthly Income

Current Monthly Expenses

Any recent financial crisis

Yes

If yes, explain

Family Members Dependent on your income

Medical bills or expenses:

Any Significant Debts

Yes

If yes, total amount owed:

Lost job due to this arrest?

Yes

Financial Impact of Legal Fees

Any bankruptcy filings

Yes

Section 14: Treatment History and Engagement

Currently in any treatment programs?

Yes

If yes, which programs?

How long in treatment?

Completed any treatment programs

Yes

If Yes, Which Ones

Attendance at treatment

Excellent

Good

Fair

Poor

Previous Treatment Programs

Medications Currently Prescribed

Compliance with Medications

Excellent

Good

Fair

Poor

Willing to Engage in Treatment

Yes

Unsure

Section 15: Current Legal Situation

Current charges:

Date of arrest:

How do you feel about the charges:

Do you accept responsibility:

Yes

Partial

Any remorse for your actions:

Yes

Understanding of victim impact:

Prior criminal history

Yes

If yes, list prior convictions

Any pending cases

Yes

Currently on probation or parole

Yes

Section 16: Victim Impact Mitigation

Do you understand how your actions affected others?

Yes

Describe the impact on victims:

Any attempts to make amends:

Yes

If yes, describe

Willingness to participate in victim impact programs:

Yes

Letter of apology written:

Yes

Restitution Ability

Section 17: Character Witness Information

Person 1

Person 1 - Name

Person 1 - Contact Information

Person 1 - Relationship

Person 1 - How Long Known

Person 2

Person 2 - Name

Person 2 - Contact Information

Person 2 - Relationship

Person 2 - How Long Known

Person 3

Person 3 - Name

Person 3 - Contact Information

Person 3 - Relationship

Person 3 - How Long Known

Employer references:

Religious/spiritual leaders:

Community members:

Section 18: Collateral Consequences Analysis

Employment consequences from arrest:

Housing situation affected:

Yes

Educational enrollment affected:

Yes

Government benefits at risk:

Yes

Child custody concerns:

Yes

Professional license at risk:

Yes

If yes, which licenses:

Immigration consequences:

Yes

Family relationships affected:

Yes

Section 19: Rehabilitation Potential and Future Goals

Short-term goals (next 6 months):

Long-term goals (next 2-5 years):

Steps already taken toward rehabilitation:

Support system for rehabilitation:

Barriers to rehabilitation:

Motivation level for change:

Very High

High

Moderate

Low

What would help you succeed:

How has this experience changed you:

Section 20: Standardized Assessment Completion

Complete the following standardized assessments (attach as separate documents):

• PHQ-9 (Depression Screening)

• GAD-7 (Anxiety Screening)

• PC-PTSD-5 (PTSD Screening)

• AUDIT-C (Alcohol Screening)

• ACE (Adverse Childhood Experiences)

• DAST-10 (Drug Abuse Screening)

• MDQ (Mood Disorder Questionnaire)

If available:

• LSI-R (Level of Service Inventory-Revised)

• CTQ (Childhood Trauma Questionnaire)

• SASSI-4 (Substance Abuse Screening)

• Beck Depression/Anxiety Inventories

Additional Documents Needed

• School records

• Medical records

• Employment records

• Military records

• Prior treatment records

• Character reference letters

• Photos/family documents

• Awards or certificates

• Prior criminal history

• Immigration documents

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