DWI and DUI Intake Form - King Law Group, PLLC

Full Name

Date of Birth

Were you over 21 at the time of the offense?

Yes

No

Best Phone Number to Reach You At

Email Address

What else are you being charged with?

Do you have any prior drug or alcohol offenses? If so, what are they?

Describe briefly the facts leading up to your arrest, that is, why do you feel that you were stopped?

Also, why did the officer say he stopped you and do you believe him?

What did you say to the police officers and what did they say to you? What questions did the officers ask you? It is important that you answer this in detail. Were Miranda warnings (i.e., you have the right to remain silent, anything you say can and will be used against you …) given to you, and if so, when? What had you told the police prior to the warnings? After the warnings?

If there was another vehicle involved in your arrest, what conversation did you have with the driver or passenger of the second or third vehicle?

Were there any passengers in your vehicle when you were stopped? Before you were stopped? Were any of them under 16? (Give all details)

Any statements made by you to others, when given and to whom?

If you performed the field sobriety tests, what were the conditions?

For example, rainy weather, it was at an angle, it was in the mud, it was on rocks, etc.

Did the officer say if you passed you would not be charged?

What clothes were you wearing and what type of shoes (if any) did you have on?

Were you involved in an accident? If so, give details.

How much heavy physical activity had you done before you were approached by the officer and what was it?

How many hours had you been awake at the time you were approached by the officer?

If you were given a blood test, was it done by a nurse? If Not, who did it?

Which of the Following Tests Were you given?

Portable Breath Test Not At the Station

Breath Test at the Station

Blood Test

Urine Test

I was offered a blood test

Yes

No

Did anyone try to talk you out of taking the breath test, blood test, or urine test?

Yes

No

If your vehicle was searched, was any alcohol, drugs, or drug paraphernalia found?

Yes

No

Please Check Which Field Sobriety Tests You Performed

The Eye Test (follow my finger/pen)

The Walk & Turn

The One Leg Stand

Other

Do you believe you were intoxicated at the time of your arrest?

Yes

No

Did you believe you were intoxicated to the point it affected your driving or you were above .08 Blood Alcohol Content?

Yes

No

What had you had to eat in the 12 hours prior to your arrest?

Describe the drinks you had prior to your arrest (what were you drinking, and the size of the drinks, the time of each drink, approximate alcohol % in each, etc.)

How much do you weigh?

When did you start drinking and in whose company were you at that time?

Name, address and telephone number of all persons with you during the time you were drinking.

Would these persons be willing to testify that you were not under the influence of alcohol or drugs?

Yes

No

Are you currently under the care of a doctor or on prescription medication? If so Explain.

Do you have a diagnosed medical condition that causes you to have imperfect balance or limp? *

(such as neck, knee, or ankle surgery)

Did you have any injuries at the time of the arrest?

Had you seen a dentist within the 24 hour period prior to the arrest?

Yes

No

Were you taking any of the following:

Do you have a speech impediment?

Yes

No

Have you been PREVIOUSLY DIAGNOSED with any of the following medical conditions?

Did your car have any mechanical defects that effect how it operates? If so, explain.

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