Client Information Please fill out this form as thoroughly as possible. Please enable JavaScript in your browser to complete this form.Make sure you have an internet connection before hitting submit. If you hit submit and the page doesn't load, then hit back. Don't hit reload.Client's NameCase number(s) & county/counties/city/citiesDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgegenderMaleFemalessnEmailYour form will also be emailed to this address.CitizenshipAliases/NicknamesAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDriver's License NumberStateClassCell PhoneFamily InformationMarital StatusSingle/never marriedMarriedSeparatedDivorcedWidowedSpouse's NameSpouse's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChildrenNames, ages & genderParentsNames, contact info, whether they're living, and whether you keep in touch with themSiblingsNames, ages, & whether you're close to themFirst Alternate ContactFirst alternate nameRelationshipAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFirst Alternate PhoneSecond Alternate ContactSecond alternate contact nameSecond relationshipAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone EmploymentEmployerPhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupervisor's NameOk to call you at work?YesNoIncomeFrequencyWeeklyMontlyBiweeklylongPrevious EmployerBondStatus of BondOut on bondHasn't posted bondHeld without bondType of BondSurety (w/ bondsman)Recognizance (OR/PR)CashBond set at $Bondsman's NameBondsman's Phone Number Criminal HistoryArrests & ConvictionsList all arrests and convictions. Include date, location (city/county/state), and case number (if known).Probation & ParoleAre 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.MitigationMental HealthHave 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.Current HealthDo you have any physical disabilities or illnesses? Are you taking any medication? Please List.Alcohol & Drug UseHave 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.Military HistoryInclude branch, whether active/guard/reserve, rank, honors/medals, type of discharge, entry date(s), discharge date(s).EducationLevel of education & anything you are currently working on. Include last grade/degree completed, when, & where.Community InvolvementVolunteer work, church involvement, etc.Situation Growing UpBriefly 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.ReferencesList name & contact info for anyone who you think could provide a positive reference for you Employer, teacher, pastor, community leader, volunteer organization member, etc.Any other questions or issues that you'd like to discuss with me?Is there anything else that I should know that could be helpful in your defense?Representation GoalsList 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.NameSubmit