DUI/DWI Defense Intake Form
Full Name
Date of Birth
Phone Number
Email Address
Date of Arrest/Incident
Location of Arrest
Charges Filed
Court Date (if known)
Prior DUI/DWI Offenses?
No
Yes
Details of Prior Offenses
Were you given a breath, blood, or urine test?
No
Yes
If yes, what type?
Test Results (if known)
Additional Information