Preliminary Interview

Record this information while its still fresh in your memory.

Please include contact information.

**Please answer the questions as truthfully as possible.** Do not guess an answer (approximations are fine, but not as reliable). The results depend on your truthfulness.

Use the *Send to Ken* button at the end of the form to submit your answers.

**All information is strictly confidential.**

Personal Information


Your Home Address

Date of Birth

Driver's License Number*

State Where Licensed*

Do you currently have a Commercial Driver's License?
 Yes No

Email Address

Please indicate any restrictions on phone calls:

Home Phone

Business Phone

Cell Phone


Contact Preference (how do you want to be contacted, i.e. be discrete, email, etc.)?


Place of Employment

Annual Income

Your Current Arrest Matter

Is it your goal to win your DWI case?
 Yes No

Date of your Current Arrest

For Texas, scheduled to appear in which County?

Case Number

What date and time is your court date?

Have you ever been arrested for DUI/DWI before?
 Yes No
If you have had prior DWIs please list them below.
Please include month/year, court, & court results.

Are you currently on probation or parole?
 Yes No

Please check below all other tickets/charges received with this DWI:
 Speeding Illegal U-turn Running red light Defective equipment Careless Driving Failure to yield

Other (please indicate type of charge):

What did the officer indicate to you as the reason for the traffic stop or contact with you? (check all that apply)
 Speeding Weaving Involved in accident - no injury to anyone Involved in accident - injury to at least one person Roadblock / checkpoint Unknown He/she didn't tell me

Other (please indicate the reason for the stop of your vehicle or contact with you):

Did the officer see you driving, or if he/she did not, did you admit to driving a vehicle?
 Yes No I don't know/Not applicable

Was there an accident?
 Yes No Not Sure
Was anyone injured? (check all that apply)
 No one was hurt  Myself Passengers(s) in my vehicle Passenger(s) in another vehicle Pedestrian Not sure

Did you drink any alcoholic beverages, and/or take any drugs, within 10-hours of being stopped by the officer?
 Yes No I don't know / Not applicable
If you drank alcoholic beverages, what type? (check all that apply)
 None consumed Beer-regular Beer-microbrew Beer-malt liquor Wine-red Wine-white Gin Vodka Rum Tequila Martini Long island ice tea
Other (please indicate type of beverages):
Think about the drinks you had. Many people underestimate how many drinks they had, or cannot remember. This can be extremely important to your case though. In order to calculate your Blood Alcohol Level please indicate how many drinks you had total (one drink is equal to a 12-ounce beer, a regular 4-ounce glass of wine, 1-shot [1.5-ounces] of hard liquor)?
Number of servings of alcohol:

Approximately what time did you finish your LAST alcoholic beverage?

If you were on prescription medications or other drugs, what type? (select all that apply)
 Not applicable Anti-depressant Pain medication Valium/tranquilizer Marijuana Methamphetamine Powdered cocaine 'Crack' cocaine Heroin Ecstasy
Other (please indicate type of medication or drug):

Did you take any field balance/coordination (field sobriety tests [FST's]) tests prior to being arrested and handcuffed?
 Yes No I don't know / Not applicable Refused
Were you ordered or did you do them voluntarily?
 Ordered Voluntary
Please select the field sobriety tests you were ordered to perform (check all that apply)

 Did not take any field tests Follow a pen, finger, or other object with your eyes Standing with my head titled back and eyes closed, feet together Standing on one foot for a period of time Patting your hands together Counting on your fingers Saying or writing the ABC's Walking a straight line, or heel-to-toe Touching your nose with finger

Other (please indicate what they made you do):

Did the officer advise you that tests were 100% optional and that no penalty would result from not doing them?
 Yes No
Did you fail to satisfactorily perform the balance and coordination tests as demonstrated to you by the officer?
 Yes No I don't know / Not applicable

Did you blow into a field breathalyzer or hand-held type gadget?
 Yes No
If you know, what was the result of the hand-held breathalyzer gadget test?

Did the officer advise you that you could refuse to take the hand-held gadget breath test?
 Yes No I don't know / Not applicable

Did you take a blood, breath or urine chemical test? (check all that apply)
 None Blood Breath Urine I don't know
Did you take the chemical test within 2 hours of driving?
 Yes No I don't know / Not applicable
If you took at least one chemical test, did you elect (choose for yourself) the chemical test?
 Yes No I don't know / Not applicable
If you took at least one chemical test, enter the test(s) and the results you know:

If you are charged with refusing a chemical test, where or when did you supposedly refuse?
 I took the chemical test. He/she told me I would have my license suspended if I refused, and I refused anyway. I refused during the initial vehicle stop or contact with the cop. I refused when they handcuffed me. I refused in the patrol car. I refused in the patrol car, on the ride to the chemical test location. I refused at the chemical test location. I refused everything from the beginning. I refused when he first stopped me. I refused when we were doing the field tests. I refused when at the station, but he didn't tell me I would loose my license if I refused. He/she told me I could refuse the test when he used a hand-held breathalyzer, so I did. He/she never told me I had to take a test and he didn't tell me I would loose my license for refusing.
If you refused, but later changed your mind, please give details:

What type of law enforcement officer was the arresting officer?
 Highway Patrolman/Trooper Local Sheriff Deputy City Police Officer Other Law Enforcement Officer
Please input the arresting officer's last name and badge or serial number:

Please input the testing officer's last name and badge or serial number:

Please input the agency that the officer worked for (i.e. Austin Police Department):

Did the officer treat you fairly and professionally?
 Yes No
Please enter any comments about the officer below:


If you have check your answers...