DWI Questionnaire

DWI Questionnaire
Thank you for contacting the DWI GUYS. The following is a DWI questionnaire and is essential in helping us determine the strengths/weaknesses of your case to provide you as many options as possible. Please be very thorough and honest as everything provided is confidential.

Please note: At the end of this questionnaire, you will be able to upload pictures of any paperwork that you may have. So if you have any paperwork, you may want to have that available to you.

PERSONAL INFORMATION
What is your full name (First Middle Last):*

First NameMiddle NameLast Name
Cell Number (include area code):*

Area CodePhone Number
If needed and able, would it be appropriate for us to contact you via text message? (message & data rates may apply)*

YesNo
Alternative Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
What is your email address?*
example@example.com
What is your mailing address (be sure to include city, state, and zip):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this the same as your physical address?

YesNo
What is your physical address? (be sure to include city, state, and zip):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are your living arrangements?

Live with selfLive with significant otherLive with parentsLive with roommatesOther - Write In
Please provide the names and relationship of the people you reside with
Date of Birth

MonthDayYear
Date
What country were you born?
What is the name of the school you last attended, or currently attend?
Do you currently participate in any sort of community service or volunteering program? If so, please briefly describe.

MEDICAL INFORMATION
In a few words, how do you describe your general health?
What is your weight?
What is your height?
Do you smoke or vape?

YesNo
What do you smoke and how often?
Any recent changes in your diet and/or physical activity? If so, please explain:
What did you have to eat the day of the incident?
What, if any, medications are you currently prescribed by a medical professional and what symptoms are those medications intended to treat?
What, if any, therapies are you currently prescribed by a medical professional and what symptoms are those therapies intended to help?
Have you ever been treated in a hospital for more than 10-hours for a single injury or illness? If so, please briefly describe.
Have you ever had any work done in your mouth, such as dentures, bridges, caps, braces, jewelry, bindings, etc.? If so, please briefly describe.
Do you use any corrective means for your vision, such as glasses, contacts, Lasik, etc.? If so, please briefly describe what is corrects.
What, if any, psychological disorders have you been counseled for, currently and in the past?
What, if any, are the names and addresses of any "doctors" you, or a dependent, are scheduled to attend in the next 45 days? Write none if none.
What, if any, are the names and addresses of any "dentists" you, or a dependent, are scheduled to attend in the next 45 days? Write none if none.
What, if any, are the names and addresses of any "counselors" you, or a dependent, are scheduled to attend in the next 45 days? Write none if none.

GOALS/CONCERNS
Please describe your concerns about the charges that you are facing?
What is your primary goal of representation?
What is the best form of Communication?

TICKETS
Please upload pictures of your tickets for our teams to review. Please make sure the tickets are legible to streamline the process. (Browse to find your ticket, then click Upload to add them to your submission). If you have an issue or the file is too big, that's OK...move on.

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DWI Questionnaire

PERSONAL INFORMATION

MEDICAL INFORMATION

EMPLOYMENT INFORMATION

CASE INFORMATION

GOALS/CONCERNS

TICKETS