1. Copyright © Kulus Consulting & Development 2016
These materials may not be commercially reproduced, but copying for other purposes, with credit, is encouraged.
1
Kulus Consulting and Development
Phone: 778-355-3136 Email: kulus@shaw.ca Website: www.gladuereports.com
GLADUE REPORT PRE-INTERVIEW FORM
Surname: _____________________________________________________________________________________
Given names: _________________________________________________________________________________
Any other names you are known by: _______________________________________________________________
Date of Birth (day/month/ year): __________________________________________________________________
Place of Birth: ________________________________________________________________________________
Telephone #: __________________________________________________________________________________
Cellular Telephone #: ___________________________________________________________________________
Other means to contact you (please specify): _________________________________________________________
Social media site profiles (please provide): __________________________________________________________
Present/Last known Address: _____________________________________________________________________
Aboriginal Nation/s: ____________________________________________________________________________
Are there any other Aboriginal Communities that you may have a connection (please specify):
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Location of Community: ________________________________________________________________________
Biological Parents / Family
Mother's Name: ________________________________________________________________________________
Aboriginal community: __________________________________________________________________________
Contact Information: ____________________________________________________________________________
Is/was she connected to her community? (In what way?) _______________________________________________
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Father's Name: ________________________________________________________________________________
Aboriginal Community: _________________________________________________________________________
Contact Information: ____________________________________________________________________________
Was she connected to her community? (In what way?) _________________________________________________
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Siblings (in order of birth), and contact information:
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Biological Grandparents, Nation, and contact information (if applicable & known to you)
Maternal Grandmother: ___________________________ /___________________/__________________________
Maternal Grandfather: ____________________________/___________________/__________________________
Paternal Grandmother: _______ ___________________/___________________/___________________________
Paternal Grandfather: __________________________/____________________/___________________________

2. Copyright © Kulus Consulting & Development 2016
These materials may not be commercially reproduced, but copying for other purposes, with credit, is encouraged.
2
Do/did you have a relationship with your Grandparents?
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The report will include information about your childhood. Are there significant events that occurred in your
childhood? Please provide an overview.
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Involvement with Ministry/Foster/Adoptive Parents and Siblings (as it relates to care or generally?) Please provide
age of contact, circumstances, applicable dates, and contact information (if known to you):
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The Courts are also interested in knowing about your immediate family. To assist the writer could you give me
information about your spouse or partner, children, step-children etc. Name, details, and contact information for
your spouse/partner/children (if applicable):
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Are there other supports in your family and community that could assist you? Any other family or community
supports? How do you know that person/community organization and do you have contact information?
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Living Arrangements
Please provide some information about where you are living; last known address, how long you were there, living
conditions, etc. - If released today, where would you go, and who would you live with - please provide contact
information for corroboration of this information:
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3. Copyright © Kulus Consulting & Development 2016
These materials may not be commercially reproduced, but copying for other purposes, with credit, is encouraged.
3
Education
Please list the schools (elementary, high school, post-secondary) that you attended, level of attainment, and describe
whether you ever experienced any behavioural or learning challenges. If so, were you provided with any
assessments, diagnosis, or educational supports - please provide details:
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Employment History
Please list your employers, contact information, time frames, and sources of income:
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Please provide information concerning any other marketable skills, certificates, interests, or aspirations that you may
have:
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Finances
How do you support yourself or your family? Please detail your present source of income, and detail whether you
have any savings, assets, or outstanding debts/fines:
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Substance History
Please detail your age of introduction, the circumstances, and history of any substance misuse. Can you provide any
information about In addition, please provide information regarding any interventions, treatment, or supports in this
area:
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Mental and Physical Health
Have you ever been assessed or provided with any diagnosis? Do you have any history of self-harm, or suicide
attempts? Have you been or are you presently under the care of a clinician, or been prescribed any medications?
Please provide a description of your physical health:
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4. Copyright © Kulus Consulting & Development 2016
These materials may not be commercially reproduced, but copying for other purposes, with credit, is encouraged.
4
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Criminal History
Please provide a brief history and description of your involvement with the criminal justice system from date of first
arrest, to present date:
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Aboriginal community
Please provide any details known to you regarding your Aboriginal community:
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Connection to Aboriginal community
Please provide details regarding your awareness, involvement, and participation with any cultural or community
events within your community. If there are elders or other community members who can speak to this, please
provide their contact information:
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Indian Residential School & Intergenerational Impacts
Please provide a detailed account of your family, community, or your own involvement with the Indian
Residential or Indian Day School system. If applicable, please also detail how this has impacted you within your
own life:
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