Confidential Profile First Name only(Required) First Gender(Required) Female Male Age(Required) Phone(Required)Address (City, State Only)(Required) City State Please list the reason(s) why you want to stop shoplifting:(Required)Approximately, at what age did you start shoplifting?Why do you think you started shoplifting? Peer Pressure Angry Depression Thrill Other Did you ever stop shoplifting for awhile? Yes No How long? When you were shoplifting most frequently, how often was it?(Required) Daily 2-3 times/week Weekly Bi-Weekly Monthly or less How many times were you caught and NOT turned over to the police?(Required) Once Twice Three times or more How many times were you turned over to the police?(Required) Once Twice Three times or more Approximate date(s) of prior arrests:Most Recent Arrest(Required) Month Day Year Prior Arrest(Required) Month DD Year Prior Arrest(Required) Month DD Year Do you have a charge pending now?(Required) Yes No (If Yes, answer:)Date of arrest Month Day Year Store Name: Court Date Month Day Year Are you currently on Probation(Required) Yes No What penalties have you received from any store, police or court? Civil Fine Court Fine Community Service Probation Jail Time Have you shoplifted since your last apprehension?(Required) Yes No Are you shoplifting currently?(Required) Yes No Life Profile:Did any of your parents shoplift? Yes No Not sure Work Status:(Required) Working Not Working If not working, reason why? Laid Off On Disability Terminated If not working, how long haven't you been working? Desired Career Marital Status(Required) Single Married Divorced Widow/Widower Seperated In a Relationship Relationship with current spouse or significant other: Good Fair Poor Does not apply Comments, if any:Do you have children? None One Two Three or more Relationship with Father (when living):(Required) Good Fair Poor Comments if any:Relationship with Mother (when living):(Required) Good Fair Poor Comments, if any:Your rating of your childhood: Good Fair Poor Comments, if any:Things troubling you now:(Required)
