Name:
Phone:
Email:
Comments:

DWI/DUI Prospective Client Questionnaire

Rest assured, this information will be kept STRICTLY CONFIDENTIAL

Please fill out this form prior to calling us. This information will help us better understand your case and you will have the important information we need to evaluate your case properly. This information is confidential and protected under the attorney/client privilege.

Contact Information
Name:
Address:
City:
State:
Zip:
Phone Number:
Cell:
Email:

Information About Prior Problems

Have you been convicted of a DWI/DUI in Louisiana
or another jurisdiction in the last ten years?
Comments:
Do you have any other criminal convictions
within the last ten years?
If so, please give date and offense:

Information About This Arrest

Date of this Arrest:
Other Charges at the time of this Arrest:
Arresting Agency:
If Other:
Parish of Arrest:
Did you take any Field Sobriety Tests?
If so, which ones?
(Check all that apply)		 Horizontal Gaze Nystagmus Test (Pen-light test)
Walk and Turn
One Legged Stand
Alphabet Test
Other Test
If Other, please describe:
Did you take the breath test or blow into the machine?
Are you willing, if necessary, to pay for expert witnesses for your defense?
Do you have an occupation that is in jeopardy if you are convicted of DWI?

Thank you for completing this questionnaire.

By clicking the submit button below, your information will automatically be sent to my assistant. We be in touch to set up a time that is convenient for you to talk about this within One Working day after receiving this information. Joe Long, Attorney At Law