Online DWI Intake

Preliminary Interview

Record the details while they are still fresh in your memory. Answer as accurately as you can, and do not guess when you do not know.

Tell Ken what happened

The form begins with your contact information and then asks about the arrest, the traffic stop, field tests, chemical testing, and the officers involved.

If you were arrested within the last 15 days, call 512-469-6056. This form is not a substitute for protecting a license deadline.

The information is sent to Ken Gibson for review. Submitting the form does not create an attorney-client relationship.

Full Name

Home Address

Date of Birth

State Where Licensed

Do you currently have a Commercial Driver's License?Do you currently have a Commercial Driver's License?YesNo

Email Address

Cell Phone

Home Phone

Business Phone

Please indicate any restrictions on phone calls

How would you prefer to be contacted?

Occupation

Place of Employment

Annual Income

Date of Your Current Arrest

For a Texas case, in which county are you scheduled to appear?

Case Number

Court Date and Time

Have you ever been arrested for DUI or DWI before?Have you ever been arrested for DUI or DWI before?YesNo

If yes, list the month/year, court, and result for each prior arrest

Are you currently on probation or parole?Are you currently on probation or parole?YesNo

Other tickets or charges received with this arrestOther tickets or charges received with this arrestSpeedingIllegal U-turnRunning a red lightDefective equipmentCareless drivingFailure to yield

Other charge or ticket

What reason did the officer give for the stop or contact?What reason did the officer give for the stop or contact?SpeedingWeavingAccident without injuryAccident with injuryRoadblock or checkpointUnknownThe officer did not tell me

Other reason for the stop or contact

Did the officer see you driving, or did you admit that you were driving?Did the officer see you driving, or did you admit that you were driving?YesNoI do not know / Not applicable

Was there an accident?Was there an accident?YesNoNot sure

Who, if anyone, was injured?Who, if anyone, was injured?No oneMePassenger in my vehiclePerson in another vehiclePedestrianNot sure

Did you consume alcohol or take any drug within 10 hours of the stop?Did you consume alcohol or take any drug within 10 hours of the stop?YesNoI do not know / Not applicable

Alcoholic beverages consumedAlcoholic beverages consumedNoneRegular beerCraft beerMalt liquorRed wineWhite wineGinVodkaRumTequilaMartiniLong Island iced tea

Other beverage

Approximate number of standard servings of alcohol

Approximate time you finished your last alcoholic beverage

List any prescription medication, nonprescription medication, or other drug

Did you perform any field sobriety or coordination tests before arrest?Did you perform any field sobriety or coordination tests before arrest?YesNoI do not know / Not applicableRefused

Were the field tests ordered or voluntary?Were the field tests ordered or voluntary?OrderedVoluntaryI do not know

Field tests you were asked to performField tests you were asked to performFollow an object with my eyesStand with head back and eyes closedStand on one footPat hands togetherCount on fingersSay or write the alphabetWalk a straight line heel-to-toeTouch nose with a fingerNo field tests

Other field test or instruction

Did the officer say the field tests were optional?Did the officer say the field tests were optional?YesNoI do not know / Not applicable

Do you believe you completed the field tests satisfactorily?Do you believe you completed the field tests satisfactorily?YesNoI do not know / Not applicable

Did you blow into a handheld breath-testing device?Did you blow into a handheld breath-testing device?YesNoI do not know / Not applicable

Result shown by the handheld device, if known

Did the officer say you could refuse the handheld breath test?Did the officer say you could refuse the handheld breath test?YesNoI do not know / Not applicable

Chemical specimen requested or takenChemical specimen requested or takenNoneBloodBreathUrineI do not know

Was a chemical test taken within two hours of driving?Was a chemical test taken within two hours of driving?YesNoI do not know / Not applicable

Were you allowed to choose the type of chemical test?Were you allowed to choose the type of chemical test?YesNoI do not know / Not applicable

Chemical test type, location, and result, if known

If a refusal is alleged, where or when did it occur?

If you later changed your mind about testing, explain

Type of arresting officerType of arresting officerDPS trooperSheriff's deputyCity police officerOther law-enforcement officer

Arresting officer's name and badge or serial number

Testing officer's name and badge or serial number

Law-enforcement agency

Did the officer treat you fairly and professionally?Did the officer treat you fairly and professionally?YesNoI do not know / Not applicable

Comments about the officer or the investigation

Before sending this form, please confirm:Before sending this form, please confirm:I understand that submitting this form does not create an attorney-client relationship.

Preliminary Interview

Tell Ken what happened

Talk to me before you talk to anyone else

The Law Office of Ken Gibson