SECTION 1 – Interview Information
Interview Date:	Time Interview Began:	Time Interview Ended:
Interview Place:
SECTION 2 – Juvenile Respondent Information
Juvenile Name:
Address:
City:	State:	Zip:
Date of Birth:	Gender:	Male	Female	Height:	Weight:
Hair Color:	Eye Color:	SSN:
Adult with Juvenile:	Relationship:
SECTION 3 – Miranda Warning
Before we ask you any questions, you must understand your rights. The nature of the offense with which you may be charged. You have the right to remain silent. You do not have to talk to me. Anything you say can be used against you in court. You have the right to have a parent or guardian present with you during questioning. You have the right to talk to a lawyer for advice before we ask you any questions and to have him with you during questioning. If you cannot afford a lawyer, one will be appointed for you before any questioning if you wish. If you decide to answer questions now without a lawyer present, you will still have the right to stop answering at any time.
SECTION 4 – Waiver of Rights
I have read this statement of my rights and I understand what my rights are. I am willing to make a statement and answer questions. I do not want a lawyer at this time. I understand and know what I am doing. No promises or threats have been made to me and no pressure or coercion of any kind has been used against me.
Juvenile Name (Print)	Juvenile Signature	Date
I approve the decision of the above juvenile to talk to you.
Adult with Juvenile Name (Print)	Adult with Juvenile Signature	Date
SECTION 5 – Law Enforcement Officer Signature
Officer Name (Print)	Officer Signature	Date