Houston DIVERT Questionaire

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.

• Did you have a Texas Driver's License at the time of the DWI?

           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.