FREE CONFIDENTIAL ON-LINE QUESTIONNAIRE

First Name:            

Last Name:            

Address:                

City:                      

State:                     

Zip code:                      

Home Phone #            Is it OK to call you at this number?     Yes No

Alternate Phone #        Is it OK to call you at this number?     Yes No

Alternate Phone Number is    Cell Phone Work Phone Family Member Other

E-mail Address: Is it OK to e-mail you at this number? Yes No   

Driver's License #:                     

State Where Licensed:               

Date of Birth:                             

How did you find this website?    Referred By Someone Church bulletin Newspaper Online Search Buisness Card West Attorney Listings Illinois State Bar Asociation Lawyers.com Martindale Hubble Other (please specify below..)

Please specify how you found us if not listed above   

    This next section pertains to the arrest itself.

Date of Arrest:                   

Time of Arrest:                   

Day of the Week:                Sunday Monday Tuesday Wednesday Thursday Friday Saturday

City Where Arrested:         

County Where Arrested:        

State Where Arrested:       

Street or Location of Arrest:

Arresting Authority: (i.e. State Police)   

Name of Arresting Officer:   

Court Date:                         

Court Name:                       

Time Of Court:                    

What other tickets did you receive along with this DUI?   

According to the officer, why were you stopped?              

Was there an accident?    Yes No Unsure

        If in an accident, was your blood ever taken?        Yes No I Refused Do not recall Not Applicable

                If yes by whom?    

                Blood test results if known:   

 Was anyone injured?        Not Applicable No One Myself Passengers of my vehicle Passengers of the other vehicle Pedestrian Not Sure

Where you stopped as the result of a roadblock or roadside safety inspection?    Yes No

When you where stopped, did the officer have you perform Field Sobriety tests?    Yes No I Refused do not recall   or where Field Sobriety given at the police station?     Yes No I Refused do not recall

     If you were given Field Sobriety tests, which ones were they? 

                                                              Hand held Breath test

                                                               Walk Heel to Toe

                                                               Stand on One Leg

                                                              Follow a Pen/finger/light with your eyes

                                                               Say the Alphabet

                                                              Touch Your Nose

                                                              Other (Please specify below..)

Did you take a breath test?                 Yes No I Refused do not recall

What was the reading?                      

Name of Testing Officer                    

Did you take a blood test?                  Yes No I Refused do not recall Does not apply

What was the reading?                      

We need to know a bit about your background.

Is this your first DUI?        Yes No

If No, please list each and every arrest/reduction/dismissal/supervision or conviction related to Driving     Under the Influence (Please list the month, year, court location and court determination or plea)

Are you currently on probation, parole or supervision?    Yes No

    If yes, then where and for what:   

PLEASE NOTE:

Warning:

The Illinois Summary Suspension Law provides for a judicial license suspension on the 46th day following a DUI arrest if the arrested motorist either refused breath, blood, or urine testing or submitted to testing that disclosed an alcohol concentration of 0.08 or more or discloses a trace of marijuana or a controlled substance that is the result of unlawful use of marijuana or a controlled substance.

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