DUI Intake Form - Hahnah Williams, Attorney at Law, PC

Email
Date
MM slash DD slash YYYY
How Did You Hear About Us?
Basic Arrest Info
Name:
Date Of Birth:
MM slash DD slash YYYY
Date Of Arrest:
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
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:
Note that completion of this form does not create an attorney-client relationship with Hahnah Williams Attorney at Law, P.C., or Attorney Hahnah Williams.

Basic Arrest Info

Basic Personal Data

Circumstances Surrounding The Stop

Search & Seizure:

Circumstances Of Arrest

STATEMENTS:

Drinking Pattern Information

Drug Ingestion Information

Physical Condition

Do Any Of The Following Conditions Apply To You:

Condition Of Your Vehicle

Weather And Road Conditions

General Habits

Final Thoughts