Client Intake Form

E-Mail Address:

Today's Date:

How Did You Hear About Us?

Basic Arrest Info

Name:

Date Of Birth:

Date Of Arrest:

Driver's License:

Testing Type(S) After Arrest - Blood Or Breath:

Pre-Arrest Handheld Breath Test (Pas)?

Yes No

Did The Officer Accuse Of Being Under The Influence Of: Alcohol Drugs Both

Arresting Officer's Law Enforcement Agency:

Name Of Arresting Officer:

Name(S) Of Other Officer(S) Involved And Their Function:

Location Of Stop/Arrest:

Charges:

Date/Location Of Court Appearance:

Are You Currently On Probation For Any Offense: If So, Describe:

Basic Personal Data

Telephone Number:

Home Address:

Social Security Number:

Marital Status / Spouse's Name:

Children (Names/Ages):

Education:

Business Name, Address And Telephone Number:

Nature Of Your Work:

How Long Employed There:

Can You Be Contacted At Work:

Consequences Of Dui Conviction On Employment:

Previous Alcohol Related Problem(S) With The Law:

Previous Drug Related Problem(S) With The Law:

Criminal Record, If Any:

Social Media Accounts (Facebook/Instagram/Twitter, Etc.), Please Identify Account Names And Whether They Are Public Or Private:

Circumstances Surrounding The Stop

Was There Any Particular Social Or Business Reason Why You Were Drinking Prior To Arrest; If So, Explain:

If You Took Any Drugs During The 24 Hours Prior To Your Arrest, Describe Whether They Were Prescribed Or Not And The Type And Amount Of Drug Ingested:

Was There Any Particular Reason Why You Were Operating A Motor Vehicle At That Time:

List The Names Of Any Passengers In The Car With You:

Was There An Accident:

Why Do You Think The Officer Stopped You:

When Were You First Aware Of The Officer:

Describe What The Officer Did To Stop Your Vehicle And How You Responded:

Describe Where The Police Car Stopped In Relation To Your Car:

Did You Remain In Your Car Or Get Out:

What Exactly Did The Officer Do When He/She First Approached You:

Was The Officer's Gun Drawn:

Did The Officer Touch You:

When Did The Officer Ask You To Leave Your Car:

What Exactly Did The Officer Say:

What Did The Officer Tell You To Do:

State All Field Tests Conducted (For Example, Follow The Officer's Finger Or Pen With Your Eyes, Walking A Straight Line, Holding One Foot Off The Ground And Counting, Tilting Your Head Back And Estimating 30 Seconds, Pas Screening [Handheld Device You Blow Into Before You Are Arrested], Etc.) And Rate Your Performance Of Them:

Did You Believe Yourself To Have The Right To Decline To Do These Things:

When Did You First Believe You Were Not Free To Leave:

What Made You Think That:

If There Were Any Passengers In Your Car, Provide Their Names, Addresses, Telephone Numbers And Details:

Were There Any Other Witnesses At The Scene; If So, Give Names, Address, Telephone Numbers And Details:

What Did Other Witnesses Say To You:

What Did You Say To Them:

Search & Seizure:

Was Your Vehicle Searched:

Were You Searched:

Were Your Passengers Searched:

List All Property Taken And Where Taken From:

Circumstances Of Arrest

At What Point During Your Interaction With The Officer Were You Told You Were Under Arrest:

What Time Were You Placed Under Arrest:

Did There Come A Time When You Were Placed In The Police Car:

If So, Front Or Back Seat:

Before Or After You Were Told You Were Under Arrest:

STATEMENTS:

What Did You Say To The Officer(s):

What Did The Officer(s) Say To You:

What Were You Advised Of Your Miranda Rights (Right To An Attorney, To Remain Silent, Etc.):

If So, When:

What Was Said To You Before You Were Advised Of Your Miranda Rights:

When Did The Subject Of Chemical Testing First Come Up:

Were You Advised Of Your Right To Refuse Chemical Testing:

If So, When:

Exactly What Did The Police Officer(s) Say About Testing; Did The Officer(s) Read Something To You Or Just Say It:

What Did You Say About Submitting To Or Refusing The Test:

What Warnings Did The Officer(s) Give You About The Test:

Did You Take A Chemical Test; If So, Was It A Blood Test, Urine Test, Breath Test, Or Some Other Kind Of Test:

Were You Given The Choice Of Which Type Of Test To Take:

Were You Told You Could Take Another Test:

After Taking The Test, Were You Told That You Could Have Your Physician Take An Additional Test:

Were You Told You Could Contact Any Attorney Or Friend Before Deciding To

If You Did Not Know An Attorney To Call, Were You Given A List Of Attorneys To Choose From:

Where Was The Test Conducted; Detail How The Test Was Conducted:

Who Administered The Test:

What Time Was The Test Given:

Note Anything Unusual During The Test:

Were You Told The Test Result:

What Was The Test Result:

At Any Time During Your Detention, Did The Police Taunt You, Use Physical Force On You Or Handcuff You? If So, Please Provide Details:

Drinking Pattern Information

When Did You Start Drinking That Day Or Night:

Detail Circumstances:

State All Alcohol Consumed, Quantity And Time Of Consumption:

Did You Consume Any Alcohol After You Were Arrested:

Did You Consume Any Alcohol After You Stopped Driving But Before The Police Arrived:

State Any Additional Information Or Anything Else Unusual That Occurred During Your Arrest Or When The Chemical Test Was Administrated:

Drug Ingestion Information

Beginning Three (3) Days Prior To Your Arrest, Describe Any Drugs Ingested, Including Prescription Medication(S) (Whether Prescribed Or Not) Or Non-Prescription (Illicit) Drugs:

For Each Medication/Drug Ingested, Please Detail The Name And Amount/Dosage Ingested:

For Each Medication/Drug Ingested, Please Detail The Date And Time Ingested:

For Each Medication/Drug Ingested, Do You Currently Have A Prescription: Yes No

For Each Medication/Drug Ingested, Have You Previously Had A Prescription: Yes No

Physical Condition

What Was Your Weight On The Date Of Arrest:

What Was Your Height On The Date Of Arrest:

What Did You Eat During The 12 Hours Before The Arrest: State Type Of Food, Quantity And Time Consumed:

How Many Consecutive Hours Had You Worked In The 12 Hours Prior To Arrest:

How Many Hours Of Sleep Did You Get During The Last Slumber Period Prior To Being Arrested And What Time Did You Awake:

List Clothing And Footwear Worn At The Time Of Arrest And Their Condition:

Do You Wear Glasses Or Contact Lenses, And If So, Were You Wearing Them When Arrested:

Were Your Eyes Bloodshot; If So, Explain:

Were You Injured At The Time Of The Incident:

Do Any Of The Following Conditions Apply To You:

Were You Undergoing Medical Care On The Date Of Arrest: State Reason, Name & Number Of Physician:

Do You Have Diabetes:

Do You Have Heart Disease:

Do You Have Speech Impairment:

Did You Stagger; If So, Explain:

Do You Have Any Disease Or Condition Causing Lack Of Coordination:

Do You Have Any Other Physical Disability; If So, Specify:

Did You See A Dentist Within 24 Hours Before Your Arrest:

Were You Taking Any Medication(S) At The Time Of The Incident, Either Prescription Or Non-Prescription:

Did You Belch, Hiccup Or Vomit During The Chemical Testing:

Was Anything In Your Mouth Prior To The Chemical Testing:

What Kinds Of Chemicals Were You Exposed To In The 24 Hours Prior To Your Arrest:

Was There Anything Else Unusual About Your Physical Condition; If So, Explain:

Condition Of Your Vehicle

Were There Any Mechanical Defects; If So, Explain:

Date Of Last Repair, Name Of Shop Where Repaired And Conditions Found Then:

Any Leaks In The Exhaust System At The Time Of Arrest:

Weather And Road Conditions

Describe Road Where Stopped:

Lighting Conditions:

What Was The Weather At The Time You Were Stopped:

What Were The Road Conditions When You Were Stopped:

Any Other Unusual Road Characteristics When You Were Stopped:

General Habits

On The Average, How Many Days A Week Do You Consume Any Alcoholic Beverage:

On The Average, How Many Days A Week Do You Ingest Marijuana:

How Much Do You Drink On Days When You Drink At All:

Do You Believe That You Have A Tendency To Drink Too Much Or Use Drugs To Excess?:

If You Feel You Do, Are You Prepared To Undertake A Rigorous Program To Overcome Your Problem:

Final Thoughts

Is There Anything Else About The Incident That You Would Like To Ask Me About, Or Bring To My Attention:

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