DWI INTAKE FORM. Address: Telephone: H ( ) W ( ) Other: ( ) Driver License#: Marital Status: Children: Place of work: (Name and Address)

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1 1 DWI INTAKE FORM File No.: Name: SS# Address: Telephone: H ( ) W ( ) Other: ( ) Driver License#: Marital Status: Children: Place of work: (Name and Address) Beyond the basic personal date about a client, the following questions should be address to initial client interviews for a case involving drunk driving. Date, time and place of arrest (include County where incident occurred) Officer making arrest and badge number: Governmental agency and charges: Describe briefly the facts leading up to your arrest, that is, why do you feel that you were stopped? A. 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. (Use back of this sheet if necessary) B. Were Miranda (right to an attorney, right to remain silent, etc.) warnings given to you and, if so, when? What did you told the police prior to the warnings? After the warnings?

2 2 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? (Give all details) Did the officer making the arrest observe your behavior? Any statements made by you to others? When given and to whom: Were you involved in an accident? If so, give details: Was your vehicle searched? Were you searched? State any property taken from your vehicle. Any property taken from you: TEST: Blood Breath Urine Other Given by: Time: Which tests were offered to you? Result of test: What field test were given such as touch your nose, walk a line, pick up coins or any other dexterity test?

3 3 How did you do? Did you feel that you were under the influence of an alcoholic beverage at the time of your arrest? Did the drinks you had affect your driving? Physical condition at the time of arrest: Alcohol and food consumed prior to arrest: When did you start drinking and in whose company were you at the time? Describe the drinks you had prior to your arrest (What were you drinking, the size of the drinks, etc.) Last alcohol and quantity: Time and type: What did you have to eat during the 12 hour period prior to your arrest? (Can affect alcohol absorption rate): Time and Type: What is your weight and size? What is your eye color? What is your hair color?

4 4 Name address and telephone numbers 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? Yes No Did you have any alcohol after your arrest? If so what? Were you under the care of a doctor at the time of your arrest? Have you seen a dentist within the 24 hour period prior to your arrest? Do you have any physical disability, which would cause you to limp or have imperfect balance, or did you have any injuries at the time of the arrest that would cause you to look intoxicated? Were you taking any medicine or drugs at the time such as cold pills, antihistamines, tranquilizers, weight control pills, aspirin, etc.? Do you have a speech impairment caused by a medical problem? Do you have any dental work, which could have absorbed alcohol? Do you wear false teeth? Do you have diabetes? Do you have a heart disease? Do you have any other medical problems that would influence your physical condition at the time of your arrest?

5 5 Was your stomach upset on the night in question? Was it possible your stomach could have been upset causing you to belch? How were you dressed at the time of the alleged offense? A. Was there anything unusual about your appearance that day? B. Were your clothes soiled or clean? What type of footwear were you wearing? Did you or do you wear glasses? If so, what is your corrective reading? How many hours had you worked prior to the arrest? Condition of car: Were there any mechanical defects in your car? Weather and Road Conditions: Blacktop Dirt Road Other Dark Light Foggy Rainy Sleet Hail Snow Drizzle Slippery Normal Wet Dry Were you advised that you could take another test? Were you advised you could have your physician take an additional test? Were you advised you could refuse the test? Were you advised that you could contact an attorney before deciding whether or not to take a test?

6 6 If you did not know of an attorney to contact, were you provided with access to a telephone book? Were you provided with a private room to call your attorney? Were you told that you were under arrest? Were you placed in jail and did they release you to anyone on the date of the DWI or did you have to spend the night in jail? Did they allow your witnesses, if any, to witness the breathalyzer and/or performance test? Did you appear before a magistrate? What amount of bond was set? Were there any conditions placed on your bond? Was your bond secured, unsecured or cash? Have you ever been convicted of DWI before? If so, state when: Were you represented by counsel? (Give details) Comments: