Pretrial Intake Form
1. Demographics & Contact Info
All questions required. Type N/A if not applicable.
Today's Date
-
Month
-
Day
Year
Date
Legal Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Preferred Name
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact (Name/Relationship/Phone):
Living Situation:
Transportation Available:
Employment Status:
Employer/Position:
Length of Employment:
Education Level / Currently in School:
Legal & Case-Related Information
All questions required. Type N/A if not applicable.
First DUI/DWAI/Criminal Charge:
Prior Charges:
Previously on Probation/Parole/Pretrial:
Currently on Probation/Parole:
Pending Cases in Another Jurisdiction:
Attorney Name/Contact:
Upcoming Court Dates (besides current):
Incident Details
All questions required. Type N/A if not applicable.
Date & Time of Incident:
Location (In town / Highway / Other):
County:
Arresting Agency:
Reason for Stop (swerving, speeding, accident, etc.):
Accident Involved:
If yes, did you report it?
Did you remain at the scene?
Field Sobriety Test (Pass/Fail):
Breathalyzer (Result or Refused):
Blood Draw (Result/BAC):
Mental Health
All questions required. Type N/A if not applicable.
Diagnosed Conditions:
Currently in Therapy/Counseling:
Currently Seeing a Psychiatrist:
Medications Prescribed:
Current Mental Health Status:
Safety Assessment (SI/HI/Self-Harm Concerns):
Medical
All questions required. Type N/A if not applicable.
Hospital Visits for Substance Use:
Substance Use Treatment History (Inpatient/Outpatient/AA):
Any ER Visits or Medical Emergencies Related to Substance Use:
Current Medical Conditions or Prescriptions:
Substance Use & Lifestyle
All questions required. Type N/A if not applicable.
Current Alcohol/Drug Use (Frequency):
Participated in AA/NA or Support Groups:
Previous Sobriety Period (Length):
Interested in Treatment/Support Now:
Signature
Continue
Continue
Should be Empty: