2. First Name
3. Last Name
5. Date of Birth
   Date of Birth
6. Age
7. Driver's License #
8. State
10. Address
12. City
13. State
14. Zip Code
16. Last 4 of SSN:
17. Date of Arrest
    Date of Arrest
18. Arresting Agency
19. Arrest Charge
21. Lenawee County Resident

    1. Yes
    2. No
22. US Citizen

    1. Yes
    2. No
    3. Unknown
23. Does this individual have a mental health diagnosis?

    1. Yes
    2. No
    3. Unknown
24. Any previous mental health diagnosis?

    1. Yes
    2. No
    3. Unknown
26. Case Worker's Name:
27. Phone Number
28. Health Insurance Coverage?

    1. Yes
    2. No
    3. Unknown
29. If yes, who is the Carrier/Provider?
31. Registered Sex Offender?

    1. Yes
    2. No
    3. Unknown
32. Any prior violent crime convictions?

    1. Yes
    2. No
    3. Unknown
33. Was a firearm involved in current charge?

    1. Yes
    2. No
    3. Unknown
35. Comments:
37. Completed by:
38. Date
    Date
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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