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2. Defendant Full Name:*
4. Respondent's email: *
6. Phone number:*
8. Age at time of offense:*
10. Gender:*
12. School:*
14. Was your school in session when this happened?

    1. Yes
    2. No
16. Offense(s):*
18. If shoplifting, what store?
20. If shoplifting, has this store requested money from you due to this charge?

    1. Yes
    2. No
22. Except for this offense, have you ever received non-traffic ticket or had contact with the police?

    1. Yes
    2. No
24. If yes, please explain:
26. Have you ever participated in Teen Court?

    1. Yes
    2. No
28. If yes, where?
30. Does this charge involve any gang activity OR are you involved in a gang?

    1. Yes
    2. No
32. Do you believe you did anything wrong?

    1. Yes
    2. No
34. Were you skipping school at the time of the incident that brought you here?

    1. Yes
    2. No
36. Was anyone affected/harmed emotionally, psychologically, financially, or physically, by this crime?

    1. Yes
    2. No
38. If yes, who was harmed and how?
40. Do you think there is anything you should do to repair the harm to those your actions affected?

    1. Yes
    2. No
42. If yes, what?
44. Do you feel you owe anyone an apology?

    1. Yes
    2. No
46. If yes, who?
48. Do you believe your actions have any impact on the people around you?

    1. Yes
    2. No
50. Who were you with(if anyone) at the time of the incident?
52. What do you like to do for fun? *
54. Do you get along with your family?

    1. Yes
    2. No
56. What does your family like to do together?*
58. Have you ever used drugs/vape/cigarettes (before this incident)?

    1. Yes
    2. No
60. If yes, what kinds of substance(s)?
62. How many times? (please give an accurate number since the 1st time used)
64. Have you ever drank alcohol (without parental permission/not at a family event)?

    1. Yes
    2. No
66. How many times have you drank? (please give an accurate number since the 1st time used)
68. What are your personal strengths and talents?
    
70. How do you cope with stress or sadness? *
72. Do you feel like you can talk to your parents or friends about problems?*
74. Are there any circumstances you want us to consider such as a tough time at school, illness or death of a family
    member or friend that may play a factor into the reason for the actions that brought you to Teen Court? *
76. Please give your version of the incident that has brought you to Teen Court: *
78. Do you hereby consent to the release of any records that pertain to my case to Teen Court personnel, student attorneys, student panelists, and student jurors. Teen Court personnel and students may see information from the school named below and/or any records from any criminal justice agencies, courts (including Teen Courts) and the Douglas County District Attorney’s Office.
    

    1. Yes
    2. No
80. If you agree, please enter your name here as an electronic signature of your consent:*
82. By signing your name here, you solemnly swear or affirm that all of the information given above is true and correct to the best of your knowledge and belief. You will give your full attention to all Teen Court proceedings that take place in my presence, and will not divulge any information that comes to your knowledge in the course of a Teen Court session.*
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83. Submit

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