BANNOCK COUNTY MISDEMEANOR PROBATION

Initial Check-In Form

Instructions:
1. This form must be answered by the probationer in BLUE or BLACK in ONLY.
2. Answer all questions completely and to the best of your ability.
3. Please be honest and accurate.
4. Return this form to your Probation Officer during your first appointment.
5. Everything on this form is considered CONFIDENTIAL information and will NOT be divulged to anyone without your consent.

Our goal is to help you succeed while on probation, to better your life, and not return through the criminal justice system. Please let
us know if you have questions regarding this process.

Section 1: Personal Information

Name: ____________________________________ ____ __________________________ ____________________________
Last First Middle

Gender: ☐ Male ☐ Female Ethnicity: ☐ Hispanic ☐ Non-Hispanic

Race: ☐White ☐American Indian/Alaskan Native ☐ Asian/Pacific Islander ☐ Black ☐ Other___________________________

Primary Language: ____________________________ Do you need an English translator? ☐ Yes ☐ No

Date of Birth: _______________ ___ Place of Birth ______________________ ______ _________________

mm/dd/yyyy City State Country

Are you a legal U.S. Citizen? ☐Yes ☐No (please explain) _______________________________________________________

DL or State issued I.D. #: ________________ ______ _______________ Social Security #: ___________________________

State Expiration Date
ID Valid? ☐Yes ☐No (why) ____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Other names used: ____________________________________________________________________________________________

Please list nicknames, and all other names (last, first, middle), and any other DOB’s or SSN#’s used

Height: _______________ Weight: _______________ Hair Color: __________________ Eye Color: ___________________

Scars/Marks/Tattoos ______________________________________________________________________________________________________

Do you have a vehicle? ☐Yes ☐No (what is your main transportation method) __________________________________________

Vehicle Make Model Year Color Plate Number

1.
2.
Phone Numbers Number Ok to Call? Emergency Only? Primary Number? Smart Phone?
Cell Phone ( )_______ - _______________ Yes No Yes No Yes No Yes No
Home Phone ( )_______ - _______________ Yes No Yes No Yes No Yes No

Work Phone ( )_______ - _______________ Yes No Yes No Yes No Yes No

E-Mail Address: _______________________________________________________________________________________________

Please mark all that apply:

Please Explain
☐I have a medical condition
☐I am a Registered Sex Offender
☐I have hate ideology
☐I am insulin dependent
☐I have anger/violence tendencies
☐I have a history of seizures
☐I have a history of mental illness
☐I use a wheelchair, walker or cane
☐I have a physical handicap

Please provide a “personal message contact” of someone (preferably) that does NOT live with you that we may contact
in the case of any emergency in our office:

Name Current Phone Number Current Address Relation to you?

( )

Section 2: Living Arrangements

What is your current address?

__________________________________________________________________________________________________
Address Apt # City State Zip

Date you moved there: ____________________ How long have you lived there: ___________ Type of housing: __________________________
Mm/dd/yyyy (approximate) house, apartment, shelter, etc.

Do you own, rent, lease or none? ______________________

Who lives here with you?

Name (last, first) Relationship Phone Number & Type How long have you known them?

Do you stay anywhere else? ☐Yes ☐No

If yes, where: ________________________________________________________________________________________

Address Apt # City State Zip

How often do you stay there? ______________________________

Who stays here with you?
Name (last, first) Relationship Phone Number & Type How long have you known them?

Section 3: Employment

Do you have a job? ☐yes ☐no (why) _____________________________________________________________________________

If yes, where do you work: _______________________________________________ Date Started: ________________________

How long have you worked here? __________________ Part time or Full time: ___________ Hours work per week: _____________

Work address: ________________________________________________________________________________________________

Address City State Zip

Work phone: ________________________ Occupation: _______________________ Wages per month: ______________________

Name of Supervisor:_______________________________________ Supervisor phone:____________________________________

Work Schedule (Days/Hours):___________________________________________________________________________________

Section 4: Military Background

Have you served in the US Military? ☐Yes ☐No, If yes: Fill out appropriate information below

Year enlisted: ______________ Year discharged: ____________ Combat? ☐ Yes ☐ No

Branch Served in: ____________________________ (eg: US AIR FORCE, etc)

Section 5: Family
What is your marital status?
☐ Single ☐ Married ☐ Divorced ☐ Separated ☐ Have a significant other ☐ Widowed

How often do you have contact with family members?

☐ Daily ☐ 2-3x a week ☐ Weekly ☐ 2-3x a month ☐ Monthly ☐ 2-3x a year ☐ 1x a year ☐ Never

Are you pregnant? ☐ Yes ☐ No ☐ N/A If yes, how many months: ________

How many children do you have? ____________ How many live with you? ____________
How many are minors? _____________ How many live with you? ____________

Section 6: Demographics

What was your age at first arrest?

☐ 9-18 years old ☐ 19-22 years old ☐ 23 or older

How many times have you been arrested (including Juvenile arrests)?
☐ 10 or more ☐ 4-9 times ☐ 0-3 times
Do you have a high school diploma, equivalent or GED?
☐ yes ☐ no
Please explain highest grade completed or highest degree obtained: ___________________________________________________
__________________________________________________________________________________________________

What is your current age range?

☐ 18-30 years old ☐ 31-44 years old ☐ 45 or older

Do you own or possess any firearms or ammunition?

☐ yes ☐ no

Have you ever been charged or arrested for a domestic violence related offense?
☐ yes ☐ no
If yes, please explain: ______________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Have you ever been the victim of domestic violence?

☐ yes ☐ no, if yes, please explain: ___________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Other than your current probation offense, do you have any other felony or misdemeanor charges in Idaho or a different state?
☐ yes ☐ no, If yes, please list the charge & state:______________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Do you have any pending cases in Idaho or a different state?

☐ yes ☐ no
If yes, please list the charge and state: ________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________

Do you have any short term goals (3-6 months)?

☐ yes ☐ no
If yes, please list the top 2:
1.) ____________________________________________________________________________________________________
2.) ____________________________________________________________________________________________________

Do you have any long term goals (1-2 years)?

☐ yes ☐ no
If yes, please list the top 2:
1.) ____________________________________________________________________________________________________
2.) ____________________________________________________________________________________________________

Please briefly tell us about what happened that led to your current probation:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Section 7: Drug, Tobacco & Alcohol Use

Substance & Alcohol Use:

Primary Choice Secondary Choice Third Choice
Type of Drug or Alcohol
Age first used
How often do you use
How do you administer
(inject, inhale, oral, smoke)
Date last used
Days used in last 30 days
Who do you use with?

1. Are you in alcohol or drug treatment, if yes specify:_______________________________________________________________

2. Are you abusing prescription drugs, if yes specify:________________________________________________________________

The responses given above are truthful to the best of my knowledge.

Signature:________________________________________________ Date:_____________________________

Probation Officers review:__________________

Probation Officers initials
 Bannock County Adult Misdemeanor Probation
Release of Information
I, ________________________________________, authorize any provider, counselor, law enforcement,
or person requested by Bannock County Probation Office to release the following information from the
record(s) in their custody including but not limited to:
 Contracts – made by telephone, mail or in person
 Treatment plans
 Assessments/evaluations including recommendation for treatment or programming
 Summary discharges and/or completion records
 Progress reports and/or notes including attendance records
 Compliance or non-compliance with program/plan records
 Drug or alcohol testing records including but not limited to attendance and results
 Medical records
 Incident reports
 Criminal background information or reports
 Or any relevant information requested by a Bannock County Probation Officer

This consent is valid until the completion of probation supervision and the release of the named individual
from the authority of Bannock County Probation.

This information is being released for the purpose of case planning and monitoring compliance with the
terms and conditions of probation supervision. The information may only be released to:

Bannock County Adult Probation

130 N. 6th Avenue Pocatello, Idaho 83201
Phone: 208-236-7002 / Fax: 208-236-0682

I release Bannock County, Bannock County Probation, and any party providing the information from any
and all liability regarding the release of information I have agreed to in this document. I have reviewed this
document and am aware that I have the right to revoke this consent through a written request at any time.

THIS CONSENT REQUIRES THAT A PROBATION OFFICER WITNESS THE SIGNATURE

_______________________________ ____________________
Probationer’s Printed Name Date of Birth

_______________________________ ____________________
Probationer’s Signature Social Security #

____________________
Date of Signature

_______________________________ ____________________
Probation Officers Printed Name Date

_______________________________
Probation Officer’s Signature
 BANNOCK COUNTY
AGREEMENT OF SUPERVISION

Name: Case:
Judge:

I, _______________________________, agree to be directed and supervised by Agents of the BANNOCK COUNTY

MISDEMEANOR PROBATION office and to be accountable for my actions and conduct to the BANNOCK COUNTY
COURT. I further agree to abide by all conditions of probation as ordered by the court and set forth in this Agreement,
consistent with the laws of the state of IDAHO. I fully understand that violation of this agreement and/or any conditions
thereof, or any new convictions for a crime, may result in action by the Court causing my probation to be revoked or my
probation period to be extended.

1. VISITS: I understand that visits to my place of residence and/or employment will be conducted by officers of the
Bannock County probation department, police, or other state and local officials for the purpose of ensuring
compliance with the conditions of the AGREEMENT OF SUPERVISION. ________

2. REPORTING:
a. Reporting: I will report as directed by my supervising officer. ________
b. Residence: I will not change residence without first notifying my supervising officer and the courts. I will
maintain a valid, working telephone number and will report any change immediately to my supervising
officer. ________
c. Travel: I will not leave Bannock County without prior approval from my supervising officer. I will provide
timely notice (3 days prior to travel) by providing my supervising officer with a completed travel request
form. I understand that travel requests may be denied based upon circumstances. ________

3. CONDUCT: I will respect and obey all laws and comply with any lawful requests of my supervising officer or any
law enforcement or peace officer. I will immediately report any law enforcement contact to my supervising officer.
________

4. WEAPONS: I will report possession or access to weapons, explosives or other similar items to my supervising
officer. I understand and agree that any firearms, ammunition, weapons, contraband, etc. may be seized by any
probation department officer. This rule is for officer and public safety and, in most cases, is not intended to
prohibit lawful use of said items. Cases related to domestic violence are regulated by Federal laws which
expressly prohibit the possession of firearms or ammunitions for anyone convicted under the domestic violence
codes, including misdemeanors. ________
(As directed by probation officer) All weapons in my place of person and/or residence must be locked by means of
container and/or trigger lock._________
I own weapons. YES / NO They are stored in my home. YES / NO
As directed by my supervising officer I may not own, purchase, or carry any weapons. _________

5. CHEMICAL ANALYSIS: I will not use or possess any controlled substances unless lawfully prescribed to me by a
licensed physician. I will not purchase, use, or have in my possession any mind-altering substances, synthetic or
otherwise illicit. I will not possess or purchase any devices, apparatus, or paraphernalia that is or could be used to
consume or ingest the mentioned prohibited substances nor will I possess or purchase any devise or apparatus
that is or could be used as an attempt to alter drug and alcohol test results. I agree to submit to urine analysis and
breathalyzer testing, at my own expense, as requested by my supervising officer or any staff member of the
Bannock county Probation Department. ________
I understand that I am required to submit to blood, breath or urine testing, that I must provide a sample in a timely
manner as directed by Averhealth or it will be considered a refusal. I understand that any attempt to dilute my
urine sample can and will be considered a positive test result. I further understand that the cost of any test(s)
performed will be at my sole expense and that the said expense shall be paid immediately. ________

6. SEARCHES: As term of my probation I will waive my 4th amendment. I agree and consent as a term and condition
of probation to a search of my person, automobile, residence, and any property under my control, any place,
anytime, by any probation officer or any law enforcement officer acting at the direction of a probation officer. Any
right to the contrary under the United States and Idaho Constitutions is hearby waived by me as a term of my
probation. ________

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 7. SEIZURES: I understand that any officer of the Bannock County probation department can and may seize ANY
ILLEGAL property, contraband, or item(s) that are deemed inappropriate for my control or possession. The
supervising officer may release the item(s) back to me – if the item(s) are not illegal in nature and not used as
evidence in any probation violation or new criminal case or proceeding after the successful conclusion of
probation. ________

8. ASSOCIATION: I will not knowingly associate with any person who is involved in criminal activity or who has
been convicted of a misdemeanor OR felony without the approval of the supervising probation officer. ________

9. EMPLOYMENT/EDUCATION: I will obtain and maintain appropriate full-time employment and or participate in an
education or vocational program as directed by my supervising officer. ________

10. TRUTHFULNESS: I will conduct myself in a truthful, cooperative, courteous and civil manner at all times with
probation, law enforcement, court staff, Averhealth staff & treatment providers. ________

11. SUPERVISION FEES: I will reimburse the county for the cost of my supervision at the rate of $35.00 a month. I
understand that should I fail to pay the fines and costs ordered by the court in accordance with financial contracts
(enacted with Judicial Enforcement office – room 103), that said fines and fees will be sent to a collection agency.
That said agency will assess an additional 33% of the money owed as a collection fee. ________

12. RESTITUTION: I shall pay restitution and other fees as ordered by the court in the sum of $___TBD ___,
according to my court financial agreement(s). ________

13. JAIL ORDERED: I shall report to the appropriate county detention facility on the dates and times specified on the
Court Order of Commitment. I also understand that if discretionary jail time is ordered by the court, that my
supervising officer may impose those days as an alternative to a probation violation. ________

14. SPECIAL CONDITIONS: ________

a.
b.

Reinstate license when eligible (if currently suspended). If I don’t have an Idaho drivers license, I will obtain one as
soon as I’m eligible.
Complete an alcohol/drug evaluation immediately or within ________ days . Ensure that a copy of that evaluation
is provided to my supervising officer immediately after completion. Complete ANY/ALL recommendations made by
the evaluator.
Complete an alcohol/drug program on ___________ or before ___________. Complete ANY/ALL recommendations
made by their facility. Provide proof of completion (and quarterly progress reports) to your supervising officer.
Complete _____ hours of community service at a pre-approved and pre-arranged facility. Pay the community service
fee prior to beginning ANY work performed ($_______). Complete ALL hours of community service on or BEFORE
_____________. Turn in timecard as directed by your supervising officer.
Other:

I have read, understand, and agree to be bound by this agreement. If I violated any of the conditions of this agreement or
my sentencing order, the Court may revoke my Probation and take appropriate action against me, and I hereby
acknowledge a copy of this agreement.

Dated this ______________________________________. ________________________________________________

Defendant

I hereby acknowledge that I have discussed, in detail, the foregoing Bannock County Agreement of Supervision – terms
and conditions of Probation with the above listed client.

________________________________________________
Probation Officer/Court Officer/Judge
Witnessing Signature

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 BANNOCK COUNTY DRUG TESTING INSTRUCTIONS

You have been ordered by the Court to undergo drug and/or alcohol testing as a condition of your probation.
The following instructions will inform you of the testing policies and procedures. Failure to comply and any
positive test result, or refusal to provide a specimen, is a violation of your probation and will be reported to
the Court, which may result in sanctions being imposed and revocation of your probation.
1. The majority of drug testing will be conducted through Averhealth at the office located at 746 E.
Lander in Pocatello, Idaho, or alternatively, at a site designated and approved by your Probation
Officer.
2. You are required to notify the probation department and Averhealth of any prescription and non-
prescription medication being used; to provide verification of any prescribed medication; and to
provide the name of your physician.
3. You will be tested randomly through Averhealth, and in addition may be required to test at the
discretion of your Probation Officer. Any increase or decrease in the frequency of drug testing will
depend on the results of your drug tests and your overall compliance with the conditions of
probation. The cost of the drug test through Averhealth will be $15.00 (unless otherwise instructed
by your Probation Officer). All costs associated with testing will be due in full on the day of
testing. Averhealth will accept cash, debit or credit card (.50 cent fee will apply to all debit/credit
card payments). If you are requested to test at the discretion of your Probation Officer any additional
testing costs will be at your expense and determined at the time of your testing by your Probation
Officer.
4. YOU WILL BE ASSIGNED A PIN #: __________________________.
For the duration of your required testing you are instructed to call the drug testing message line at
208-286-4404 or 208-240-9033, you may also log into my.averhealth.com. You must call this
message line or login every day, 365 days per year including weekends and holidays.
You are required to listen to the entire message until you hear a confirmation number. The daily
call in message line hours are 5:00 am – 8:00 am. On the days you are instructed to test you may
show up any time between the hours of 7:00 am – 11:00 am (weekdays) or 7:00 am - 10:00 am
(weekends & holidays).
 Report for your first test between 7:00 am – 10:00 am to complete intake
process with Averhealth.
 On weekdays, the testing staff will allow you one last opportunity to provide a
sample up to 11:30 am, but not if you came in after the 11:00 am cut off time.
 On weekends and holidays, the testing staff will allow you one last opportunity to
provide a sample up to 10:30 am, but not if you came in after the 10:00 am cut off
time.
Failure to report or provide a specimen is equivalent to a REFUSAL and is a violation of your
probation. You must call 7 days a week – including weekends and holidays.
6. If you are instructed to test outside of Averhealth testing your Probation Officer will provide you with
further instruction and any costs that may be associated with this testing.

QR code to complete your registration with Averhealth:

I, the undersigned, have read the above instructions and reviewed them with my Probation Officer. I
understand that failure to comply with these instructions is a violation of probation and may result in the
revocation of my probation.

_________________________________________________ _________________________
DEFENDANT SIGNATURE Date

_____________________________________________________________ _________________________
PROBATION OFFICER Date
 IN THE DISTRICT COURT OF THE SIXTH JUDICIAL DISTRICT IN
THE STATE OF IDAHO IN AND FOR THE COUNTY OF BANNOCK,
MAGISTRATE'S DIVISION

STATE OF IDAHO )
Plaintiff, ) Case No:
vs. )
)
) WAIVER of 4th
) Amendment Rights
Defendant. )

I, ____________________, who resides at ___________________________________,

Am on probation with the BANNOCK COUNTY PROBATION OFFICE and am under

the jurisdiction of the BANNOCK COUNTY MAGISTRATE COURT. As a consequence,
I have waived my rights under the FOURTH AMENDMENT of the Constitution as
applied to searches and seizures. I consent to warrant less searches of my person, my
property (locked or otherwise secured), computers, Cellular Phones, cellular phone
records, automobiles (entire vehicle and the contents contained therein), residence
(under the control of myself), blood, breath, or urine at the request of police officer or
probation officer.

Dated this__________________________.
__________________________________________
Defendant Signature Waiving 4th Amendment Right

__________________________________________
Defendant PRINTED NAME

___________________________________
Probation Officer / Witness to waiver