Free Online Evaluation

Please provide your name and a telephone number at a minimum. The remaining information on this page is optional but helps us evaluate your case. For example, the medical questions that we ask relate to some of the field sobriety tests, the accuracy of breath testing, and issues relating to blood testing. All information that you provide in connection with this intake form will be kept in complete and strict confidence.
City
State
Zip Code
Main Phone
Alt. Phone
E-Mail Address
What is your current occupation?
(This can be an important because of the adverse consequences of a conviction.)
Do you have a CDL?
yes
no
Do you have a professional license threatened by a DUI conviction?
yes
no
What is the date of this offense?
At what time were you arrested?
Breath
Blood
First Result
Second Result
Third Result
yes
no
Result?
yes
no
                              MEDICAL / PHYSIOLOGICAL                              
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
yes    
yes
no
no    
no
no    
no
no    
no
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no
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no
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no
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no
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no
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no
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no
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no
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no
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no
Full Legal Name
Street Address
What time were you stopped by the police? 
(This information can be found on your temporary driver's license.)
Why were you stopped by the police?  (Be specific.)
City and police department handling the arrest:
What are the current charges?  (List all offenses, i.e. OWI 1st, PBT refusal, driving while suspended, etc.)
Did you take a breath test or a blood test?
If you know the result, what was the breath or blood alcohol level?
(If you refused the police officer's breath or blood test at the police station, please write REFUSED.)
Did you take a roadside preliminary breath test (PBT)?
Did you perform roadside field sobriety tests?
                              FIELD SOBRIETY TESTING                              
8 Do you wear dentures, a retainer or tongue ring?
8  Are you diabetic?                                                                   
8  Are you hypoglycemic or hyperglycemic?      
8  Do you wear glasses?                                                            
8  Do you wear contact lenses?
8  Have you been diagnosed with conjunctivitis?                           
8  Do you have dyslexia?
8  Have you been diagnosed or treated for glaucoma?                   
8  Do you have a "lazy eye" or are you "cross eyed"?
8  Do you have vision in both eyes?                                             
8  Do you suffer from acid reflux disease (GERD)?
8  Do you take heartburn medication?                                          
8  Do you have any type of esophageae hernia?
8  Do you have ulcers or problems with your stomach?                  
8  Are you exposed to toluene, acetone or ether?
8  Do you use an inhaler?                                                           
8  Do you have emphysema? 
8  Do you suffer from COPD?                                                      
8  Do you have asthma?    
8  Have you ever suffered a head injury?                                      
8  Do you wear a hearing aid?
8  Do you suffer from any hearing loss?                                       
8  Are you on low carbohydrate diet or the Atkins diet ?
8  Do you have back, leg, or other muscular problems?                 
8  Do you suffer from Ataxia?   
8  Have you ever head a stroke?                                                 
8  Do you have high blood pressure?    
8  Do you experience anxiety attacks?                                        
8  Have you been diagnosed with Attention Deficit Disorder?   
                              ADDITIONAL INFORMATION                              

Please provide a description of the incident along with any additional details about you or your case for our review.