Today's Date

Full name

Address with City, State, Zip

Client's Cell Phone Number

Alternate Cell Phone Number

Your email

Yes, email is an acceptable way to contact you.

Your birthday

Your current age

Date of arrest

What are you charged with?

Date of your next court appearance

Time of your next court appearance

Which court must you appear in?

Did you take the breath test? There are two breath tests; a road-side breath test and a test at the station. We are asking about the test at the station.
Yes, I took the breath test.No, I did not take the breath test.

If you took the breath test or if you were given a blood draw, what was your alleged BAC? Please enter a number between .00 and .49.

Was there a collision before your arrest?
No, there was no collision before my arrest.Yes, there was a one-car collision before I was arrested.Yes, there was a multiple-vehicle collision before I was arrested.

Have you ever been charged or convicted of DWI, DWAI, DUI, BUI, OUI, Wet & Reckless, or any other drinking and driving related offense at any point in time, anywhere in the United States or Canada?
Yes, I have a prior drinking and driving charge or conviction.No, I do not have a prior drinking and driving charge or conviction.

Please list all criminal convictions (including DWI and DWAI) whether the conviction was in New York or not (excluding traffic tickets). Please note that if you have two prior felony convictions, some judges will not release you after arraignment. Please tell us about all your priors so that we can prepare.

Please describe any other court cases you are involved in, whether criminal or civil.

Do you hold a pistol permit?
Yes, I hold a pistol permit.No, I do not have a pistol permit.

Where were you born? Criminal convictions have immigration consequences.

What is your primary language? Court interpreters are free of charge.

Full name of your spouse or partner and their date of birth. We won't contact them unless you ask, but it is good for us to know how to reach them.

Do you have children that require transportation to currently scheduled medical appointments? If yes, please bring the dates, times, locations, and name of medical provider for each visit to our first meeting.
Yes, I have children with medical appointments.No, I don't have any children with medical appointments.

If there are any, please list the full names and birthdates of the children who live with you.

Are you a veteran? If so, please describe your military service.

What is your occupation? Please tell us the name and address of your employer (or your school if you are a student), along with your job title.

What is your work and/or school schedule? Please tell us the days and times (start and stop times) you work or go to class.

Are you on probation or parole?
I am on neither probation nor parole.I am on probation.I am on parole.

Are you currently being treated for any substance abuse issues? If so, please tell us your current treatment provider and give us a brief history of your treatment.

Please list any prescription medications you are on, and their daily dosages.

Please list any physical conditions that effect your balance or coordination, or any physical or mental health conditions for which you are under a doctor's care.

Describe your current living situation, and note if you live with anybody who is currently on probation or parole.

Has a judge already set pre-trial release terms such as bail, or release under pretrial supervision? Please describe.

Canada restricts entry into their country against non-Canadian citizens who are convicted of any kind of crimes including any kind of drinking and driving offense. How often, if ever, do you travel to or through Canada?
I rarely travel to Canada, and have no plans to do so.I travel to (or through) Canada about once a year.I travel to (or through) Canada multiple times a year.

We all encounter stressors in our life at one point or another. Please select any of the following stressors you are experiencing.
NoneMarriage or Relationship ProblemsDeath or illness of a family member or friendDrug or alcohol addictionPressure at workLoss of a jobIssues concerning your childrenOther

Please describe the stress you are experiencing.