Nebraska Youth Screen - Parent Version
For any juvenile cited by law enforcement, the Otoe County Attorney's Office would like certain information from such youth and his/her parent/guardian before proceeding with any criminal or juvenile court prosecution or diversion. You will be asked questions from the Nebraska Youth Screen (NYS) to aid in the processing of this matter. A separate survey link must be completed by your child. Please complete w/in 1 week of the date on the citation. If you are having difficulty with the survey please contact (402) 969-0319 or email otoecountydiversion@gmail.com.
First & Last Name: *
Your answer
First & Last Name of Child: *
Your answer
Gender of Child: *
Race/Ethnicity of Child: *
Phone: *
Your answer
Email: *
Your answer
List the offense(s) your child was cited for: *
Your answer
List any prior offenses and age at time of offense: (indicate "none" if no priors) *
Your answer
List any prior diversion or probation services your child has received? (indicate "none" if your child has received no other services) *
Your answer
What is your relationship to the child cited? *
How many live in the household? *
Please describe your relationship with your son/daughter: *
Your answer
What discipline/consequences at home have already taken place due to this incident? *
Your answer
How does he/she do in school and what is your expectation in regards to his education? *
Your answer
School he/she attends: please list *
Your answer
Grade Level: *
Typical grades: *
Has he/she ever been suspended from school? If no please indicate, if yes-please explain. *
Your answer
Has he/she ever skipped school? *
How many class periods has he/she missed in the last two weeks? *
How many days in the past two weeks has he/she been tardy from school? *
If he/she has skipped school, class periods or had several tardies please explain or indicate none: *
Your answer
Is he/she employed? *
List employment and typical hours per week.
Your answer
How many close friends would you say he/she has? *
Are you concerned with your son/daughter's friend choices? *
Was he/she intoxicated at the time of this offense? *
Has he/she ever tried alcohol? *
Has he/she ever tried marijuana? *
Has he/she ever tried cigarettes, chewing tobacco or nicotine vape products? *
List any other substances tried? (cocaine, lsd, heroin, meth, etc.)
Your answer
How often does he/she consume substances? *
Have alcohol and/or drugs impacted his/her life in a negative way? Please explain or indicate "no". *
Your answer
What activities inside or outside of school is he/she involved in? If none, indicate "none" below. *
Your answer
List activities/hobbies that most interest him/her: *
Your answer
Have he/she ever been in a physical fight? Please explain or indicate no. *
Your answer
How often does your child get angry? *
In what ways does your child demonstrate his/her anger?
Your answer
Has your child completed any type of community service in the past? Please list... *
Your answer
Does your child receive any type of community services in or outside the home: (counseling/therapy, tutoring, special education, etc.) Please list services he/she receives.
Your answer
Would you or your child like to receive additional services and/or information helpful to your family and what types if interested: (housing, food, school supplies, mentoring, counseling, etc.)
Your answer
Overall, how do you feel about the offense your child has been cited for? *
Your answer
Is there any additional information you would like to provide?
Your answer
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