* Name

* Email

* Phone
eg. (xxx) xxx-xxxx

What type of case do you need representation for?

DWI
Drug
Other

Is this your first offense?

Yes
No

If “no”, how many?

Please tell us the name of the charge or charges against you.

Please tell us the town & county of any prior arrests that you had & the year it occurred.

Were you involved in an accident in this case?

Yes
No

If “yes”, was anyone hurt, killed, or transported to the hospital?

Yes
No

Explain.

Were any of the following field sobriety tests performed (check all that apply)?

Portable Breath Test at scene
Intoxylizer Breath Test at station
Blood Test
Urine Test
Alphabet Eye Test
Head Tilt
Nose Touch
One-Leg Stand
Walk the Line

Were you arrested at the scene?

What was the date of your arrest in this case?

What county were you arrested in this case?

Do you have a scheduled court date?

Yes
No

If “yes”, when and where is your court?

How were you referred to us?

Radio
Internet
Attorney
Friend/Family/Other
Former Client