DUI QUESTIONNAIRE

Tell Us What Happened

The information below is for your records only. It is imperative that you record your account of the arrest, while the event is fresh in your mind.

Upon completing this form, you will have the option to forward it to our office. We will need this information prior to your initial consultation. If you do not forward this information to our office, be prepared to give this information over the phone.

Date of arrest:

Time of arrest:

City and state of arrest:

Exact location of arrest ( i.e. Intersection of Pacific Coast Highway & Jamboree Road)

Arresting agency:

Why were you stopped?

Do you have any physical limitations that would hinder your ability to take the field sobriety tests?

Which field sobriety tests did you take? Please check all that apply.

Alcohol Gaze Nystagmus

Standing on One Foot – Balance

Walking Imaginary Line

	Finger Counting
	Alternate Clapping

How do you feel you did on these tests? Please elaborate.

Did you take a blood or breath test, or did you refuse all chemical testing? Please check all that apply.

Blood test

Breath test on a small hand-held device at the scene

Breath test at the police station or other location

Refused all but the breath test at the scene

Refused all tests

What were the results of these tests?

Were you advised that you had a right to refuse the breath test?

Were you advised that if you refused that you would lose your license for 1 or 2 if you had priors?

Were you advised that there was mandatory jail time if you refused and were convicted?

Were you advised that your refusal could be used against you in court?

Did the officer confuse you in any way?

What county and court is your case in?

When are you to appear?

Have you ever been arrested for any other alcohol or drug offenses?

Biographical Information

What is your name?

What is your address?

List the phone numbers where you can be contacted.

Can messages be left at these numbers?

What is you email address?

Age

Sex

Weight

Occupation

License necessary for employment

Please enter the word seen below:

In addition to clicking the "Submit Query" button above, please copy and paste this information in an e-mailto:info@simonslaw.com.

Call 949-497-1729 for a free consultation.