Client Information

Please fill out this form as thoroughly as possible.

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Your form will also be emailed to this address.

Family Information

Names, ages & gender
Names, contact info, whether they're living, and whether you keep in touch with them
Names, ages, & whether you're close to them

First Alternate Contact

Second Alternate Contact



Criminal History

List all arrests and convictions. Include date, location (city/county/state), and case number (if known).
Are you currently on probation/parole/a suspended sentence/a deferred sentence/post-imprisonment supervision or have any other pending charges? List charges, status, case number, and location.


Have you ever been under the care of a psychiatrist/doctor/psychologist or been treated for mental illness? If so, when and where? Include any prescriptions affecting mental ability.
Do you have any physical disabilities or illnesses? Are you taking any medication? Please List.
Have you ever been treated for an alcohol or drug problem? If so, when and where? In your opinion, was the treatment successful? Include any treatment programs attended as part of probation or earlier prison time.
Include branch, whether active/guard/reserve, rank, honors/medals, type of discharge, entry date(s), discharge date(s).
Level of education & anything you are currently working on. Include last grade/degree completed, when, & where.
Volunteer work, church involvement, etc.
Briefly tell me your life story. Begin from when you were born; tell me about the way you grew up; tell me about your parents, family, spouse, children, teachers, friends, employers, and anyone else significant for both good and bad reasons; tell me about your life today and what caused you to be here. Include any history of abuse, living in foster care, etc.
List name & contact info for anyone who you think could provide a positive reference for you Employer, teacher, pastor, community leader, volunteer organization member, etc.
List your goals for this representation (besides dismissal). Stay out of jail, not go to trial, not become a convicted felon, shortest time possible on probation, not lose CDL, eligible for expungement, treatment for drug addiction, etc.