Confidential DWI Client Questionnaire

CONFIDENTIAL DWI CLIENT QUESTIONNAIRE

Date of Completion of Form:

DO YOU HAVE ANY DIFFICULTY READING OR WRITING? ____________

1. PERSONAL INFORMATION

Name:

Address:

Phone: Home __________________ Work ________________________

Cell ___________________ Fax _________________________

Alternate Contact Information

Name: ____________________________________ Aware of charges? □ YES □ NO

Their Contact Information:

Employer: ________________________________________________________

Date of birth: Age: Height: Weight: lbs.

SSN: Hair color: Eye Color:

Marital status:

Children:_______________

U.S. Citizen? □ YES □ NO Licensed pilot? □ YES □ NO

D.L. no. : ____________________ State:

Professional license(s):

Travel plans (Dates unavailable for court):

Educational background:

2. WHAT BROUGHT YOU TO ME?

How did you hear about me?

_____ I received a letter

_____ I was referred by ________________________________________________

_____ I found you with a ___ Google search ___ Other internet search

_____ I saw you on a coaster

_____ Texas’ Top Rated Lawyers

_____ D Magazine’s Best Lawyers in Dallas

_____ Texas Super Lawyers

_____ AVVO

_____ Charles Robley referred me

_____ Other: __________________________________________________________

Social Media:

Facebook name: _____________________________________________________

Twitter: @ __________________________________________________________

Instagram: __________________________________________________________

Other: _____________________________________________________________

___________________________________________________________________

3. ARREST INFORMATION

DATE OF ARREST: ______________ COUNTY: __________________________

Which police agency arrested you? ___________________________________

COURT DATE? _________________ COURT NUMBER? ___________________

4. OTHER OFFENSES

Were you charged with any offense other than DWI?

Offense:

Court and court date if different from the DWI:

5. ARREST HISTORY

Prior arrests, convictions, or diversions:

Charge County Attorney Disposition

Charge County Attorney Disposition

Charge County Attorney Disposition

6. DAY OF THE ARREST

What did you have to eat in the 12 hour period prior to arrest?

Are you aware of any people willing to testify that you were not under the influence?

□ YES □ NO

List Names :

Describe how you felt generally during the day of your arrest:

List the times you consumed each drink on the day you were arrested along with the type of drink, size of drink and location:

_________________________________________________________________

Time Location Type of Drink Size of Drink

_________________________________________________________________

Time Location Type of Drink Size of Drink

_________________________________________________________________

Time Location Type of Drink Size of Drink

_________________________________________________________________

Time Location Type of Drink Size of Drink

_________________________________________________________________

Time Location Type of Drink Size of Drink

_________________________________________________________________

Time Location Type of Drink Size of Drink

Did you consider yourself to be under the influence of an alcoholic beverage at the time of your arrest? □ YES □ NO

7. VEHICLE AND DRIVING CONDITIONS

Why were you stopped, if you know? ______________________________

Please list the extent of use your vehicle is used to perform employment duties:

____________________________________________________________________

Are you the primary driver in your household? □ YES □ NO

List any defects (mechanical or otherwise) in your car:

___________________________________________________________________

Were there any other factors that may have affected your driving?

8. THE OFFENSE

Date/time/place of arrest:.

Police Department: _______________________

Do you speak English fluently? □ YES □ NO

Do you believe that the officer's language or accent caused any problems in you being able to understand him/her? □ YES □ NO

Do you believe that your language or accent caused any problems in the officer being able to understand you? □ YES □ NO

Were there any passengers in the vehicle?. □ YES □ NO

Who?

Were you wearing any article of clothing that may have been considered "binding" or restrictive enough to interfere with your ability to perform any of the field sobriety tests?

□ YES □ NO

If so, explain:

Were you offered a portable breath test at the scene? □ YES □ NO

Did you take it? □ YES □ NO

9. EVIDENCE SEIZED

Was your vehicle towed? □ YES □ NO

Was your vehicle searched? □ YES □ NO

If so, was anything taken by the police and not returned? □ YES □ NO

What was it?

Did you know it was there? □ YES □ NO

Were you personally searched? □...