Criminal Defense Intake

Intake Form

“*” indicates required fields

Contact Information
Name*
First Middle Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address*
Street Address Address Line 2 City State ZIP Code
Cell Phone Number*
Email*
Your Preferred Contact Method
Emergency Contact Name
First Last
Emergency Contact Telephone Number*
Biographical Information
Date of Birth*
Month
Day
Year
English-Speaker?
If no, preferred language?
Marital Status
Children
Number of Children
U.S. Citizen
Immigration Status
Known Alias(es)
Employer's Name
Time Employed?
Job Title
Monthly Pay
Specialized Training?
Highest Education
Driver's License State & No.
Driver's License Status
Do you have a pistol permit?
Are there firearms in your house?
Military service?
Branch of Service
Please list any prior criminal or DWI/DWAI convictions and the approximate month and year of conviction
Click the plus sign to add additional convictions, if necessary.
Conviction Date
Are you currently on probation or parole?
Source of Referral
How were you referred to us?
Provide name and phone number if friend, relative, or attorney
Present Charge(s) Information
Offense(s) charged:
Date(s) of alleged offense(s):
Court Time

: Hours

Minutes

AM/PM
Court Date
Court of Jurisdiction:
Where case is pending (if known)
County of Jurisdiction (if known):
Where case is pending (if known)
Who is your current attorney for this case?
Your Version of Events
Questions You Would Like Answered by Your Attorney
Click the plus sign to add additional questions, if necessary.

Conviction	Date