DUI Intake Form | LV DUI Defense

LV DUI Defense - Full DUI Intake Test

Full retained-client DUI intake test for LV DUI Defense / Pariente Law Firm.

LV DUI Defense - Existing Client DUI Intake

For retained DUI clients only. Complete this intake as accurately as possible so your legal team can begin reviewing your DUI case.

Client Information

First Name(Required)

Middle Name

Last Name(Required)

Date of Birth(Required)

Social Security Number

Cell Phone(Required)

Home Phone

Work Phone

Email Address(Required)

Street Address(Required)

Apartment / Unit / Suite

City(Required)

State(Required)

ZIP Code(Required)

Employment / Personal Background

Place of Employment

How Long Have You Worked There?

Occupation / Job Title

Marital Status

Spouse's Name

Spouse's Phone

May your spouse have information regarding your case?

Yes

May anyone else in your family have information regarding your case?

Yes

If yes, please list names and phone numbers

Are you or have you been in the military?

Yes

If yes, which branch?

When was your service?

Honorable discharge?

Yes

Not Applicable

Arrest / Case Background

Date of Arrest or Hospitalization(Required)

Approximate Time of Arrest

Did you have a valid driver’s license?

Yes

Driver’s License State

Do you have a Commercial Driver’s License (CDL)?

Yes

Do you have a Concealed Weapons Permit?

Yes

Do you have a Pilot’s License?

Yes

Arresting Organization

Arresting Officer’s Name

Why do you believe you were stopped?

Did the officer tell you why you were stopped?

Yes

Do Not Remember

What did you say to the officer before arrest?

Weather / Road Conditions

Rain

Windy

Cold

Hot

Dark

Heavy Traffic

Construction

Other

Chemical Test

Which chemical test best describes your case?(Required)

Blood Test

Breath Test

Urine Test

REFUSAL - I refused all chemical testing

Were you asked more than once to submit to testing?

Yes

Do Not Remember

Did the officer read an implied consent warning?

Yes

Do Not Remember

Was a warrant obtained?

Yes

Unknown

Was blood eventually taken anyway?

Yes

Unknown

Explain what happened with the chemical test/refusal

Blood Test Details

Where was blood taken?

Who drew the blood, if known?

Did you see or receive a copy of a blood warrant?

Yes

Unknown

Describe anything unusual about the blood draw

Breath Test Details

Were you asked to blow into a handheld roadside breath device?

Yes

Do Not Remember

Were you asked to blow into a machine at the jail/police station?

Yes

Do Not Remember

Did you burp, vomit, regurgitate, or have acid reflux before the breath test?

Yes

Do Not Remember

Describe anything unusual about the breath testing

Accident Information

Was there an accident?(Required)

Yes

Were there injuries to anyone other than yourself?

Yes

Unknown

Accident Details

Vehicle Damage

Property Damage

Airbags Deployed

Tow Truck

EMS Responded

Hospital Visit

Passengers Present

Photos Available

Briefly explain the accident, injuries, damage, and insurance status

Field Sobriety / Roadside Testing

Field Sobriety Tests Requested or Performed

HGN / Eye Test

Walk-and-Turn

One-Leg Stand

Alphabet

Counting

Finger Count

Preliminary Breath Test

I refused field sobriety tests

Describe what happened during field sobriety testing

Were you advised of Miranda rights?

Yes

Do Not Remember

Were you questioned after arrest?

Yes

Do Not Remember

Medical History

Were you using prescription, non-prescribed, controlled substances, or over-the-counter medication?

Yes

If yes, list medications/substances and what they were taken for

Physical defects/ailments that may have caused poor field sobriety performance or appearance of intoxication

Medical Conditions / Issues

Explain any checked medical issues

Were you physically ill at the time of arrest?

Yes

Timeline / Witnesses

Timeline: Please walk us through the day/night leading up to the arrest

What did you eat and drink before the arrest?

Witnesses: names, phone numbers, relationship, and what they saw

DMV / License Information

Driver’s license address status(Required)

Have you been convicted of a moving violation in the last 12 months?

Yes

Have you received a DMV revocation notice?

Yes

Unsure

Is a DMV hearing already scheduled?

Yes

Unsure

If scheduled, DMV hearing date

Do you have a court date within the next 14 days?

Yes

Unsure

Next court date

Insurance Information

Insurance Company

Claim Number

Insurance Adjuster's Name

Insurance Adjuster's Phone

Insurance Adjuster's Fax