DUI Intake Form Submission

Name:

Date of Birth:

Preferred Language:

Gender:

Phone Number:

Email Address:

Current Address:

Emergency Contact Person:

Emergency Contact Phone Number

Court Date, Time, Location, and Room Number (if known):

Were you arrested? Were you arrested? Yes No Not sure

Were you in (or on) a motor vehicle? Were you in (or on) a motor vehicle? Yes No Not sure

Did you have the key(s) to any motor vehicle on (or about) your person? Did you have the key(s) to any motor vehicle on (or about) your person? Yes No Not sure

Were you driving a motor vehicle? Were you driving a motor vehicle? Yes No Not sure

Was the vehicle registered in your name? Was the vehicle registered in your name? Yes No Not sure

Was the vehicle insured? Was the vehicle insured? Yes No Not sure

Were there any passengers in the vehicle? Were there any passengers in the vehicle? Yes No Not sure

Was your Driver's License valid? Was your Driver's License valid? Yes No Not sure

Was there an accident or crash? Was there an accident or crash? Yes No Not sure

Was there any property damage? Was there any property damage? Yes No Not sure

Were any airbags deployed in any vehicle? Were any airbags deployed in any vehicle? Yes No Not sure

Were there any injuries to you or others? Were there any injuries to you or others? Yes No Not sure

Was anyone taken to the hospital? Was anyone taken to the hospital? Yes No Not sure

Did you provide any blood or urine samples? Did you provide any blood or urine samples? Yes No Not sure

Did you admit to drinking any alcohol? Did you admit to drinking any alcohol? Yes No Not sure

Was any open liquor found at the scene? Was any open liquor found at the scene? Yes No Not sure

Did you admit to taking any illegal drugs? Did you admit to taking any illegal drugs? Yes No Not sure

Were any legal or illegal drugs found? Were any legal or illegal drugs found? Yes No Not sure

Did you admit to possessing any weapons? Did you admit to possessing any weapons? Yes No Not sure

Were any weapons found? Were any weapons found? Yes No Not sure

Were you physically cooperative with the police? Were you physically cooperative with the police? Yes No Not sure

Did the police use physical force to detain you? Did the police use physical force to detain you? Yes No Not sure

Did you perform sobriety tests (walk and turn, one leg stand, etc.)? Did you perform sobriety tests (walk and turn, one leg stand, etc.)? Yes No Not sure

Did you blow on a Breathalyzer Test? Did you blow on a Breathalyzer Test? Yes No Not sure

Did the police provide you with the results of any Breathalyzer Tests? Did the police provide you with the results of any Breathalyzer Tests? Yes No Not sure

Have you ever been previously arrested for DUI? Have you ever been previously arrested for DUI? Yes No Not sure

Do you have any misdemeanor convictions on your criminal record? Do you have any misdemeanor convictions on your criminal record? Yes No Not sure

Do you have any felony convictions on your criminal record? Do you have any felony convictions on your criminal record? Yes No Not sure

Do you have, or have you ever had, a driver's license in any state other than Illinois? Do you have, or have you ever had, a driver's license in any state other than Illinois? Yes No Not sure

Agreement on Attorneys Fees Agreement on Attorneys Fees Upon submitting this form, and in exchange for being considered for reduced or waived legal fees, if approved, I agree to make weekly payments in good faith towards Attorneys Fees, to the best of my ability, until my balance is paid in full.