DUI Client Intake Form

Thank you so much for contacting our law office. Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you.

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

CLIENT INFORMATION

Contact information

County:

Best way to reach you:

OK to leave a message?

Employer:

Driver's license state:

Do you have a commercial driver's license (CDL)?

ARREST INFORMATION

Date of arrest:

Approximate time of arrest:

Location of arrest (city/road):

County of arrest:

Arresting agency:

Ticket / case number(s):

Charges on ticket(s):

First court date:

Courthouse:

Was bond posted?

Was your vehicle towed or impounded?

Was an accident or injury involved?

TESTING

Were field sobriety tests done?

Was a breath test taken?

Was a blood or urine test taken?

Did you refuse any test?

Were you given a Notice of Summary Suspension?

PRIOR RECORD

Any prior DUI (any state)?

Do you have any other pending cases?

Are you currently on probation or supervision?

EMERGENCY CONTACT

Name:

Relationship:

Phone number:

ADDITIONAL INFORMATION

How did you hear about us?:

Anything else we should know?:

CERTIFICATION

Certification:

OFFICE USE ONLY

Date received:

Intake by:

Conflict check:

Retained?

THANK YOU