1609 West 92nd Street, Kansas City, Missouri 64114 Phone (816)471-5777 | Fax (816)471-5778 Click here to download form DUI Client Questionnaire Today's Date Basic Information Full Name Address Phone (cell) Phone (alternate) Email Ok to use YesNo Employer Employer Address Your Social Security No. Date of Birth Driver’s License No. State of Issue Do you have a Commercial Driver’s License (CDL)? YesNo Have you had driver’s licenses in other states? YesNo If so, list the state and time period in which you were previously licensed Where were you born? How were you referred to the Angles Law Firm, LLC? IndividualAttorneyInternet SiteOther (Please Explain) What is your preferred method of payment? CheckCashVisaMastercardDiscoverAmerican Express DUI/DWI Information Details win DUI cases. The only way to have a viable chance at being successful in your case is if we know as much detail as possible on the following questions. If you don’t know the answer to a question, leave it blank or indicate so. Please be assured that this questionnaire will be used in our office only, and your confidentiality will be protected. Have you ever been arrested for a DUI or DWI before? YesNo For each arrest list the approximate date and the outcome of the case (including pending cases, diversions, dismissals, convictions, etc.) A B C D Please list all prior arrests of any kind, including the approximate date of diversion, conviction, or dismissal (also, please list any pending cases) A B C D Were you on diversion or probation at the time of your arrest in this matter? YesNo Where and for what? Date of this DUI arrest Court date Court Time Name of city in which you were arrested Exact location of arrest Arrested by City PoliceSheriff’s DeputyHighway Patrol What other citations were issued (speeding, driving while suspended, etc) Were you involved in an accident? YesNo Was anyone injured? YesNo What did the officer say he stopped you for? Did the officer ask you to take field sobriety tests? YesNo Did the officer have you follow a pen or other instrument with your eyes? YesNo Did you... PassFailI Don't Know Did the officer have you stand on one leg? YesNo Did you... PassFailI Don't Know Did the officer have you walk a line heel-to-toe? YesNo Did you... PassFailI Don't Know Did the officer have you say the alphabet? YesNo Did the officer have you count numbers? YesNo Backwards? YesNo Please list any other field tests given Did the officer have you blow into a hand-held breath machine? YesNo What were the results? Did the officer tell you that you could refuse to blow into that machine? YesNo Were you handcuffed? YesNo Did the officer ever read you your rights (i.e the right to remain silent, anything you say could be used against you, right to an attorney)? YesNo When? Did the officer ever read you a list of rights about chemical testing to determine your blood or breath alcohol YesNo Did the officer make you wait 15-20 minutes before taking the test? YesNo Did the officer ever leave you alone during this 15-20 minute period? YesNo Where were you during this time period (in cop car, in a cell, at a desk, etc)? Did you cough, belch, regurgitate or put anything in your mouth during this 15-20 minute period? YesNo Did you submit to a test of your BreathBloodUrineNeither Did you ask the officer if you could take a test other than the test offered? YesNo If you asked for an alternate test, what was the officer’s reply or reaction? If you refused, did you tell the officer why you refused? YesNo Explain: Did the officer ever look inside your mouth? YesNo Did you have anything inside your mouth? YesNo Do you have gum disease or problems with bleeding in your mouth? YesNo Were you wearing contacts at the time of arrest? YesNo Have you ever had surgery? YesNo If so, when and for what? Please list any and all physical illnesses, impairments or disabilities you had at the time of arrest (including trouble with knees, ankles, back, or illness such as a cold, allergies, diabetes, or asthma) Please list any and all learning disabilities, mental illnesses or disorders you suffered from at the time of your arrest (including Attention Deficit Disorder, manic depression, schizophrenia, etc) What and when had you eaten on the date of your arrest? How long prior to the test had it been since you had an alcoholic drink? What medications were you taking at the time of arrest? What specifically do you do at your job? Do you work around any solvents or chemicals (i.e. paint, paint thinner, gasoline, etc)? YesNo Please list any persons, and their contact information, who were with you at or just prior to the time of your arrest. Do you suffer from acid reflux, GERD, or other similar problems? YesNo Do you use your car during the course of your employment? YesNo How many miles per month do you drive for work? How many miles per month do you drive total? Which defenses, if any, do you think you may have? List your main concerns going forward. Please list any other facts that you believe may be important, including what the officer said to you, how he or she treated you, and anything else that could be useful in defending your case or that you think we should know. I understand no attorney-client relationship is formed by submitting this form. I understand this form is confidential and will be reviewed by the Angles Law Firm, LLC only.
1609 West 92nd Street, Kansas City, Missouri 641141609 West 92nd Street, Kansas City, Missouri 64114