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Confidential Attorney-Client Communication

CLIENT INTERVIEW FORM

Please provide as much information as possible. Note: Fields with a * are required.

Your Name:
* Email Address:
Your Home Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Pager Phone:
Mobile Phone:
Fax Number:
Contact Preference (How do you want to be contacted?):
Date of Birth: - -
Driver's License Number and State:
Occupation:
Place of Employment:
How did you learn about our practice?
Please describe any prior military service:
Describe any charity, civic or community organizations you are involved with:
When and where is your next court date:
Please tell us the date, time and location of your DUI arrest:
Which police agency arrested you:
The arresting officer(s) name(s) (If you remember):
If you have any prior convictions for DUI or "wet reckless," please give us the date, county and charges:
If the officer pulled you over, did he explain why?:
Did the officer take your driver's license or give you a paper called Administrative Per Se Order of Suspension/Revocation, Temporary Driver License Endorement?
Yes
No
Have you contacted the DMV as requested on the Administrative Per Se Order?
Yes
No

If not, please call us toll free at 888-249-0004.
If you have contacted the DMV within the 10 day limit, when is your appointment (date and time)?:
Approximately how many minutes went by from the time you were arrested (when they handcuffed you) until you arrived at the chemical test (blood, breath or urine test)?:
Approximately how many minutes went by from the time you arrived at the chemical test location until you took the first chemical test (blood, breath or urine test)?:
Please describe the number of drinks you consumed, what you consumed and when you consumed it for a period of 8 hours before the arrest:
Please describe what food you ate and when you ate it for a period of 8 hours before the arrest:
Please select the field sobriety tests you were requested to perform? (Check all that apply):
Follow a pen, finger or other object with your eyes, not moving your head
Stand with your head tilted back and eyes closed, feet together, cout to 30
Stand on one foot for a period or time
Pat your hands together
Count on your fingers
Say or write the ABC's
Walk a straight line or heel-to-toe
Touch your nose with your finger
Other
Please describe any medical conditions, injuries or physical constraints from which you suffer (especially those that may have affected your ability to perform the field sobriety tests):
Do you suffer from GERD, acid reflux or frequent heartburn? Describe:
Do you wear braces, dentures or have active cavities? Describe:
During the several days leading up to the arrest, were you exposed to any solvents, compounds or industrial chemicals? Explain:
Describe any allergies you suffer from and whether this has been diagnosed:
Did you blow into a handheld breath machine prior to the officer arresting you?:
Yes
No
If you know, what was the result of the hand-held breath test?
I don't know/not applicable
Did the officer advise you that you could refuse to take the hand-held breath test?
Yes
No
I don't know/not applicable
Please select the type of chemical test you took (or whether you took a chemical test at all):
Blood
Breath
No Chemical Test Taken
What were the results of the test, if you know?
I don't know/not applicable
How much time elapsed between finishing your last drink and taking the chemical test?
*Anti-spam question:
 

Copyright © 2009 Shouse Law Group - California Drunk Driving Defense Lawyers - Riverside DUI Law Firm - All rights reserved.

California Drunk Driving Attorneys Disclaimer: The DUI Defense, Drunk Driving, DMV Drivers License Suspension, Driving Under the Influence, Driving While Intoxicated or other DUI defense information presented at this site should not be considered formal legal advice nor the formation of a lawyer or attorney client relationship. Any results set forth here were dependent on the facts of that case and the results will differ from case to case. Please contact a California drunk driving lawyer or attorney for a free initial consultation. This web site is not intended to solicit clients for matters outside of the State of California.

Our DUI defense law firm serves the following Southern California communities, among others: Los Angeles County, Agoura, Alhambra, Bellflower, Beverly Hills, Burbank, Calabasas, Century City, Chatsworth, Compton, Culver City, Diamond Bar, Downey, El Segundo, Encino, Glendale, Glendora, Hermosa Beach, Hidden Hills, Hollywood, Huntington Park, Inglewood, Los Angeles Lawyer, La Canada, Long Beach, Los Angeles Attorney, Malibu, Manhattan Beach, Marina Del Rey, Norwalk, Palos Verdes, Pasadena, Pomona, Rancho Palos Verdes, Redondo Beach, Rolling Hills, San Dimas, San Fernando, San Marino, San Pedro, Santa Clarita, Sierra Madre, Santa Monica, South Gate, South Pasadena, Sylmar, Torrance, Universal City, Valencia, Van Nuys, West Covina, West Hollywood, Walnut, Westchester, Westlake Village, Whittier, Woodland Hills, Orange County, San Bernardino County, Ontario, Rancho Cucamonga, Fontana, Redlands, Upland, Riverside, Corona, Norco, Santa Barbara County, and Santa Barbara.

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