Delinquent Act(s): _______________  
_______________________________ 
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_______________________________ 

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In re _______________________   

Docket # _______________________ 

ADMISSION COLLOQUY FORM 

(Juvenile)   

Answer all of the questions on this form.  If you do not understand any question, leave it 
blank and ask your lawyer or the judge.   

I admit that I did the following things (lawyer shall list the delinquent acts, grading of acts, 
and  counts):____________________________________________________________ 
______________________________________________________________________ 
______________________________________________________________________  
______________________________________________________________________  

General Information: 

What is your full name?____________________________________________

Do you have any other name or nickname? 
If yes, state: _____________________________________________________

 Yes 

 No

How old are you today? _______________

What grade are you in? _______________

Can you read, write, and understand English? 

 Yes 

 No (if yes, go to #6)

a) If you cannot read, has someone read this form to you? 

 Yes 

  No 

If so, who? _____________________________________________(print name) 

______________________________________________________  
(signature of reader verifies that the form has been read to the juvenile) 

b) If you do not read English, have you been given a translator or a lawyer who

speaks your language? 

Yes 
 

No
 

c) Did your translator or lawyer read this form to you and explain it? 

Yes 
 

 
No

1)

2)

3)

4)

5)

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If so, who? _____________________________________________(print name) 

______________________________________________________  
(signature of reader verifies that the form has been read to the juvenile) 

Knowing and Voluntary Admission: 

6)

Are you now a patient in a mental hospital?     Yes 
a) If yes, where? _________________________________________________

No
 

b) Are you being treated for a mental illness?     Yes 

 No

c) If yes, what are you being treated for?_______________________________

7)

Have you taken any drugs or alcohol yesterday or today that do not make you think
clearly?     Yes 
             If yes, specify type of drugs and/or alcohol: ________________________

 No

8)

Has anyone threatened or forced you to sign this form? 

 Yes 

 No

If yes, explain: ______________________________________________ 

9)

Have you been promised anything for this admission?     Yes 

No
 

If yes, explain: ______________________________________________ 

Understanding the Admission:  

10)

Has your lawyer told you what you did was against the law? 

Yes 
 

No
 

11)

By admitting what you did, do you understand that you are giving up:

a) the right to be presumed innocent, which means the judge does not think you
broke  the  law  until  the  D.A.  (District  Attorney)  proves beyond  a  reasonable
doubt  that  you  broke  the  law  (a  reasonable  doubt  is  a  belief  that  it  is
very  possible you did not break the law); 

 Yes 

 No

b) the right to a hearing by a fair judge; 

Yes 
 

No
 

c) the right to remain silent and your silence cannot be held against you;

Yes 
 

No
 

d) the right to tell the judge your side of the story;     Yes 

No
 

e) the right to ask witnesses questions; 

Yes 
 

No
 

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f)

the right to present witnesses or evidence to help tell your side of the story, but 
you do not have to do anything;     Yes 

 No

g) the right to tell the judge you disagree with something; 

 Yes 

 No

h) the right to ask the judge to decide if he or she should hear certain things; and 

Yes 
 

No
 

i)

the right to have a higher court review this judge’s decision. 

Yes 
 

No
 

12)

Do  you  understand  if  the  judge  accepts  your  admission  and  believes  you  need
help (finds you delinquent), the judge may make you get help?  

Yes 
 

No
 

Possible Consequences of Adjudication of Delinquency: 

Do  you  understand  that  if  you  are  found  delinquent,  the  judge  may  make  you
pay money and place you outside of your home or on probation until you turn 21
years old? 

 Yes 

 No

Are you aware that if you are admitting to ______________________________
________________________________________________________________
that your driving license will be suspended now or in the future (which means you
will not be able to drive)?     Yes     No
(Lawyer shall write acts on this line, cross off, or write n/a.)

15)

Do  you  understand  that  this  case  can  be  used  against  you  in  the  future?    For
example, if you break the law again, you may get a longer sentence in jail.

Yes 

No
 

Do  you  understand  that  if  you  are  found  delinquent,  other  people  may  find  out
about it?  You may also have to tell people, including colleges, military recruiters,
or employers? 

 Yes 

 No

Do you understand that if you are not a U.S. citizen, it may cause problems, which
could include being forced to leave the U.S.?       Yes 

 No

Do you understand that if you are admitting to sexual assault that you cannot
attend the same school as the victim?  You will either be expelled or transferred to
another school.    Yes     No

13)

14)

16)

17)

18)

Admission Agreements: 

19) Are you aware that the judge does not have to accept any agreement between you

and the District Attorney?     Yes 

No 
 

Not Applicable
 

20)

If you change your mind about admitting to the charges before the judge decides
your disposition or consequences, then you can ask the judge to let you take back
your admission.

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Appeals: 

21)

If you are found delinquent after this admission, you can have a higher court review
your case for only three reasons:

a) whether your admission was voluntary (you made your own decision to admit to
a charge. No one forced you to do this.  You understood what you were doing,
including the consequences.);    Yes     No

b) whether the court was the correct court to hear your case (the court had the

authority over your case); or 

Yes 
 
 
 
 
 
 
 
 
 
 

 No

c) whether the court abused its responsibility or made any mistakes in the things

that were ordered as your consequences. 

 Yes 

 No

22)

If you do not admit, do you understand you have other rights?  

 Yes 

 No

Lawyer’s Representation and Opportunity to Speak with Guardian 

23)      Are  you  okay  with  what  your  lawyer  did  for  you  and  how  he  or  she  explained  
          everything?  

 Yes 

 No

24)    Did you talk with your parent or guardian about admitting to the charge(s)?

 Yes 

 No

I  promise  that  I  have  read  the whole  form  or  someone  has  read  the  form  to  me.    I 
understand it.  I am telling the truth.  I am saying that I have done the things on page 1.  I 
believe that this admission is best for me.  The signature below and initials on each page 
of this form are mine.  

___________________________________________  
JUVENILE  

___________________________________________ 
DATE 

I, ______________________, lawyer for the juvenile, have reviewed this form with my 
client.  My client has told me and I believe that he or she understands this form.    

____________________________________________ 
LAWYER FOR JUVENILE   

____________________________________________ 
DATE  

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