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Houston DIVERT Questionaire

After posting the DIVERT contract yesterday I realized it would be helpful if I posted the initial questionnaire that is asked of someone before the SALCE assessment is done.  The following is asked of any person that seeks entry into the Harris County, Texas DIVERT program.

DIVERT PRE-TRIAL INTERVENTION QUESTIONNAIRE

This form must be returned to the court prosecutor and attached to the state's file upon completion.   Failure to complete & Return this form may lead to cancelation of the assessment.

PLEASE PRINT Legibly -see reverse for further details

NAME: _______________________________________
Case Number and Court _____________________________

  • Do you read, write, and fluent speak English?               YES          NO
    • If no, explain on reverse.
  • Are you a U.S. Citizen or Legal Resident?                      YES          NO          
    • If no, explain on reverse.

Please attach immigration documents if legal resident.

               

           If no, explain on reverse.

  • Are you a Resident of Harris County?                            YES          NO           
    • if no, explain on reverse.

  • Are you employed or a full time student?                      YES          NO           
    • if no, explain on reverse.

If Yes, Where_________________________________________________________________________________

  • Have you ever been known by another name?            YES           NO         
    • if no, explain on reverse.
  • Do you travel out of the Texas or U.S. regularly?         YES           NO         
    • if no, explain on reverse.

 

  • Do you have any problems (health problems, family issues, sight, hearing, travel, emotional, employment, transportation, etc.) which may affect your ability to complete community service? YES           NO          
    • if no, explain on reverse.

 

  • Have you ever been arrested, charged, or convicted of a Criminal offense prior to the Current DWI other than fine-only traffic offense?         YES           NO         
    • if no, explain on reverse.

 

  • Are you currently or have you ever been on community supervision, deferred adjudication, probation or pre-trial diversion for any offense other than a fine- only traffic offense? YES           NO          
    • if no, explain on reverse.

               

  • Other than this DWI, do you have any other criminal case pending other than a fine- only traffic offense?                  YES           NO         
    •  if no, explain on reverse.

               

  • Have you ever had a serious problem as a result of drug use?YES           NO          
    • if no, explain on reverse.

 

  • If this case involves an accident, has restitution been paid? YES           NO          
    • if no, explain on reverse.

 

  • If offered entry into DIVERT, will you be able to abstain from alcohol and drugs from the entire term? YES           NO          
    • if no, explain on reverse.


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