Personal Information

*Please type out all answers. The form will not accept copy and pasted content.

Date of Birth:

Social Security:

Military Service:

U.s. Citizen?
Licensed pilot?
Do you ordinarily have difficulty removing it from your purse, billfold, wallet, pocket?
At the time of your arrest, did the officer ask to see your driver's license?

Information About the Accident

Arrest information (This Incident)

Other offense information

If you were charged with any traffic offenses or crimes other than DUI, give the following information on EACH seperate offense:
Offense 1:
Were you aware that you committed this offense?
Any witnesses or evidence relating to this offense that supports your claim of innocence?
Offense 2:
Were you aware that you committed this offense?
Any witnesses or evidence relating to this offense that supports your claim of innocence?

Arrest history

Charge 1:
Charge 2:
Charge 3:
Charge 4:
Charge 5:

Automobile accidents where you were driving in the last 12 months?
Five years before that?

Information about vehicle driven at time of arrest

Liability Car Insurance on date of arrest?
Policy period at the time of your arrest:
Did you own the vehicle you were driving?
If you were not the owner of the vehicle you were driving at the time of the arrest, did you have liability insurance on another vehicle on the date of your arrest?
Policy Period at the time of your arrest:
If you did not have insurance at the time of your arrest, have your purchased it since?
If yes please provide:
Policy Period from the time of your arrest:
Have you investigated the cost of insurance in the event of a DUI conviction?

Medical Information

Often one's medical condition can mimic intoxication and may affect one's performance with the police. Please complete each question fully and completely. An omission can adversely affect the outcome of your case.
If you have sought medical treatment for any physical or psychological condition, please list them below in chronological order from oldest to most recent. Obtain a copy of these medical records for treatment in the past 10 years and provide me with a copy of those records.
Symptom 1:
Symptom 2:
Symptom 3:
Symptom 4:
Symptom 5:
Symptom 6:
Have you been hospitalized at any medical facility?
When was the last time you were examined by a medical care provider (physician, nurse, practitioner, chiropractor, etc.) other than for a scheduled checkup?
Are you currently under the care of a doctor?
Were you taking any medication or drugs at the time such as cold pills, aspirin, antihistamines, tranquilizers, weight control pills, etc.?
Were you warned by your doctor, pharmacists, or nurse, of any side effects of the medication?
Do you have any physical disability which would cause imperfect balance, or any injuries that would cause you to look like you were intoxicated?
Do you have a speech impediment or have you attended speech therapy classes?
Was your stomach upset at the time of arrest?
Do you suffer from gastroesophageal reflux disease (GERD)?
Do you suffer from non-alcoholic steatohepatitas (NASH), fatty liver, or any other liver condition/disease or liver enzyme abnormality?
Were you wearing corrective lenses at the time of your arrest?
Anxiety Disorder?
Do you wear dentures/false teeth/braces/other orthodontics or use a retainer?
Do you have or have you been diagnosed with any learning disabilities?
Have you been diagnosed with Attention Deficit Disorder (ADD or ADHD)?
Have you been prescribed any medication(s) for treatment of ADD or ADHD?
Had you taken your ADD/ADHD medication as prescribed on the date of your arrest?
Do you have any difficulties with coordination or balance?
Do you have any Heart diseases?
Do you suffer from any sleep disorders?
After having been arrested for an offense such as yours, most people feel "down" or "depressed." That is a natural feeling. If we accept your case, we will do whatever we reasonably can to alleviate your fears, but we are not skilled or trained in the field of psychology. However, it is still important for us to know how you are feeling since your arrest. Please check all the following that apply:
Do you currently smoke?
Do you smoke?
If you do not currently smoke, have you been a smoker in the past?

Day of Arrest

Vehicle and driving conditions

Are you the primary driver in your household?
Weather and Road Conditions (check all that apply):

The Offense

Do you speak English fluently?
Do you believe that your language or accent caused any problems in the officer being able to understand you?
At any time did you ask to speak with an attorney?
Did you tell the officer you had been drinking?
Were there any passengers in the vehicle?
Were you told you had the right to remain silent, that anything you said could be held against you, that you had the right to an attorney, etc.?
Were you wearing any article of clothing that may have been considered "binding" or restrictive enough to interfere with your ability to perform any of the field sobriety tests?
Do you recall any law enforcement officer making any inappropriate sexual remark or gesture?

Route driven

Traffic control lights?
Working Properly?


(Complete this section ONLY IF an accident of some type has occured in connection with your DUI arrest.)
Were you involved in an accident?
Were in you inside your vehicle when the officer first arrived on the scene?
Did the police officer take your driver's license from you?
After the accident, did you exit the vehicle or leave the immediate area (for any purpose, such as to call a tow truck, call police, etc.)?
Injuries or death to any other person(s)?
Do you recall the circumstances leading up to the accident?
Prior to this case, had you EVER been the driver of a vehicle in which another person (passenger, person(s) in other car, pedestrians(s) were killed?
Did you hit your head, or break the windshield?
Did you call anyone on a cellular phone after the accident?
Did the officer direct you to drive the car after the accident?
Did the officer ask you if you had anything to drink since the time of the accident?
Did you have conversation with the other driver, or with witnesses to the accident?

Roadblocks (Complete this section ONLY if you were arrested at or near a DUI checkpoint)

Was the arrest at a roadblock or license checkpoint?
Were you given any advance notice of the roadblock (was the roadblock well marked and visible)?
Was there a sign advising of a roadblock?
Lighted sign?
Orange "traffic control" cones?
Did they have their blue lights on?
Any traffic cones or flares used at "stop" location or place where you were tested?
Did you turn away from the roadbock before reaching it?
Did the officer charge you with an additional traffic violation when you turned to avoid the roadblock?

Evidence Seized

Was your vehicle towed?
Was your vehicle return to you?
Was your vehicle searched?
Was your vehicle searched?
If so, was anything taken from you and not returned?
Did you know it was there?

DUI Tests

Field sobriety tests

Did the officer direct you (or "request" you) to perform any coordiation or roadside sobriety tests?
Were you given a choice to refuse them?
Did the officer ask you about your physical limitations or impairments or present illnesses/medications before beginning to "test" you?
Were your shoes on or off during tests?
Did the officer demonstrate the tests for you?
Did the officer comment on your performance of any test or tests?
Did you refuse to take the field sobriety test?
Did the officer ask you to perform an eye test in which you were asked to follow a pen or a similiar object?
Did the officer ask you to stand on one leg?
Did the officer ask you to walk a straight line?
Did the officer ask you to close your eyes and estimate 30 seconds?
Did the officer ask you to touch your nose with the tip of finger?
Were you asked to take any other sobriety tests?
Please describe the following conditions at the scene of the field sobriety tests in as much detail as possible:
Were your passengers permitted to witness the test(s)?

Chemical tests in general

Tests Offered by Officer:
Tests Given by Officer:
Tests Refused:
Did the officers read any document to you?
Did the officers personally hand you a copy?
Did you receive a copy of the breath test result?
Were you told what would happen if you did not take the test?

Breath test (if applicable)

Did the officer remove anything from your mouth?
Did you have anything in your mouth?
Did you smoke before taking the test?
Did you belch, hiccup, or sneeze 20 minutes prior to blowing?
Did the officer have any difficulty operating the machine?
Did you request another test?
Were you allowed to take a second test?

Blood test (if applicable)

Was the blood taken from a vein near your elbow?

After the Arrest

Implied consent

Were you told that if you refused the test, your license would be revoked, suspended , or canceled?
At the time of the warning, had you been told that you were under arrest?
Were you advised that you could contact an attorney before deciding to submit to a test?
Were you refused the opportunity to consult with a lawyer before deciding to take the test?
Were you advised that after the officer's test you could take another test by medical personnel of your own choosing?
At the time that you refused the State's test(s), had the officer(s) done anything to frighten you or said or done anything to offend you to such a degree that you were unwilling to cooperate with the police?
Were you suffering any pain, discomfort or other physical or mental impairment which would have justified your refusal of (or explained your refusal of) the State's test(s)?

Actions after arrest

Were you handcuffed?
Did that make you angry?
Did you ask not to be handcuffed?
Did the handcuffs hurt?
Were you handcuffed in front of other people?
Did you suffer any numbness, pain or discomfort in your hands or arms?
Did you complain of pain from handcuffs?
Have you sought medical aid about the problem?
Did you overhear any radio transmissions to or from the officer while he/she was driving you to the testing site/jail/hospital?
Did you ask the transporting officer any questions during the trip?
Did you ask to go to a rest room?
Did the officer accompany you?
Were you cooperative with the officer?
Weather and Road Conditions (check all that apply):
Is the bonding company paid in full?


Police Report

Effects of a possible conviction

Do you ever have to prove "insurability" in order to drive a "company" car?
Do you ever need to rent a rental car, for personal or business use?
If so, would denial of access to rental vehicles affect you or your employment?
Are you involved in any "domestic" (divorce, child custody, etc.) case or judicial dispute that a DUI conviction might affect?
Are you professionally licensed (i.e., teacher, attorney) or specially licensed (i.e., pilot, cab driver, etc.) such that you may lose such license as a result of a conviction?
Does your job involve "security clearance" or "top secret" status such that your employer may be unwilling to accept a DUI conviction?
Are you currently enrolled in college or university, where you may be subject to disciplinary suspension for DUI?
Do you have a student loan which may be adversely affected by a DUI conviction?
Are you presently in military/reserves or planning to join military/reserves?
If your license is issued by another state, are you aware that there may be additional penalties and/or insurance assessments if convicted in this state?
If you have not done so already, would you like to hire a lawyer in your home state with whom we may confer?
We recommend doing so. We are not licensed to practice law in your home state and therefore are not familiar with all the laws and consequesnces that might affect you.

Please use the space below and on the back, to give me any other information you may think be important.

DUI Client Questionnaire

Get the Help You Need From Our Bakersfield DUI Lawyer

This form is for existing clients. In order to give our team a better idea of the circumstances surrounding your DUI charges and allow us to represent you to the best of our abilities, it is necessary that you answer the designated questions below, both carefully and completely. Please do not rush through the questions, but take your time to provide thorough answers with as much information as possible. If you obtained the information from someone else, please indicate so.

If you are a new client seeking representation, please click here.

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