Intake Form: Criminal Defense

Intake Form: Criminal Defense
Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Social Security Number*
Aliases / Nicknames
Date of Birth*

MonthDayYear
Primary Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
E-mail Address*

Confirmation Email
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Race / ethnicity*

AsianBlackHispanicNative AmericanWhiteOther
Sex*

MaleFemaleOther
Primary language*

EnglishSpanishOther
Are you currently incarcerated?*

YesNo
Which jail are you being held in?*
Are you currently employed?*

YesNo
Employer*
Position*
Supervisor*
Phone Number*

Area CodePhone Number
Income*
Gross dollar amount, pre-tax. Specify if annual, monthly, or weekly.
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
How many people live in your household?*
Does this include your spouse or significant other?*

YesNo
How many are below the age of 18?*
Select all that apply:*

Held without bondSecured bond servicesPersonal bondHave posted bondHave not posted bond (being held)
Secured bond set at:*
Personal bond set at:*
Arrest Date*

MonthDayYear
Type of Offense*

MisdemeanorFelonyOther
Select all that apply:*

Driving While IntoxicatedPossession of Illicit SubstancesUnlawful Possession of a WeaponUnlawful Carry of a WeaponPublic IntoxicationAssaultTheftOther
Arresting Agency*

City Police DepartmentCity Sheriff's OfficeFederalState
Name of Federal Agency*
Name of State Agency*
Court Type

CountyDistrictOther
County Court #*
District Court #*
Next Court Date and Time*

MonthDayYearHourMinutesAM/PM Option
Purpose of Court Date*
Please give your version of the events. Explain fully.*
Would you like to authorize anyone else to receive updates regarding your case?*

YesNo
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*

MotherFatherBrotherSisterSpousePartnerDaughterSon
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Would you like to authorize anyone else to receive updates regarding your case?*

YesNo
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*

MotherFatherBrotherSisterSpousePartnerDaughterSon
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: