Form

E-Mail Address:

Today's Date:

How Did You Hear About Us?

Client Intake Form

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 Responsed:

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 Where 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:

(843) 856-2222

(843) 273-8221

Client Intake Form

Basic Personal Data

Circumstances Surrounding The Stop

Circumstances Of Arrest

Drinking Pattern Information

Drug Ingestion Information

Physical Condition

Condition Of Your Vehicle

Weather And Road Conditions

General Habits

Final Thoughts

Office Location

(843) 856-2222

(843) 273-8221

Form

Client Intake Form

Basic Personal Data

Circumstances Surrounding The Stop

Circumstances Of Arrest

Drinking Pattern Information

Drug Ingestion Information

Physical Condition

Condition Of Your Vehicle

Weather And Road Conditions

General Habits

Final Thoughts

Office Location

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