LAW OFFICES OF STEVENS, HARRIS GUERNSEY PC

ATTORNEY RONALD F. STEVENS

Interview Questionnaire

DWI/DUI Client Interview Form

Print and fill out this form or the Acrobat Reader [ click here ] version. Please answer all of the following questions as candidly and completely as possible. This information is extremely important in evaluating your case, in determining whether there are defenses to the case, in deciding whether plea negotiation is preferable to trial, and in determining trial strategy. The information you give will remain confidential and will be used only to assist in the preparation of your case.

Personal Data

Name
Address
Email
Telephone numbers (Home/Business/Mobile/Pager)
Age
Date and Place of birth
Height and Weight
Educational background
Service in armed forces Yes No
Employment (name, address, and telephone number of employer; responsibilities and duration)
Marital status (name of spouse and children)
What Search Engine Did You Use to Find Our Website?
What Query Did You Use to Find Our Website?

The Arrest

Date, time, and place of arrest and reason for initial stop
Name and badge number of officer making arrest
Name and badge number of officer conducting field sobriety test
Name and badge number of officer conducting horizontal gaze nystagmus test
Name and badge number of officer conducting chemical test
Describe the facts leading up to your arrest, including anything you said to the police officer(s) and everything the police officer(s) said to you. Please supply as much detail as possible.
Were any Miranda warnings given to you, such as the right to have an attorney, the right to remain silent, etc., and, if so, what was said to you by the police both before and after the warnings? etc.?
To the best of your recollection, when were the warnings given to you?
Did you respond either verbally or otherwise to the warnings given?
Did you give any indication to the officer that you either did not understand your rights or had a question about your rights? If so, what did you say and what were the officer's responses?
Did you have any conversation with the driver of any other vehicle, any pedestrians, or anyone else other than the police? If so, please relate the substance of those conversations as best as you can recall.
Were you given any field sobriety, or coordination tests (walk-the-line, heel-to-toe, picking up coins, finger-to-nose, stand-on-one leg, divided attention, recitation of the alphabet, etc.)?
If so, what tests were you given, when and where were they given, and how do you feel you did with respect to each test? If you refused to take any of these tests, was anything told to you by the police concerning any ramifications or consequences of the refusal?
How long after being stopped were you asked to perform these tests?
When and where did you perform these tests? Were these tests administered on a hard, dry, smooth and level surface?
Do you have any medical conditions (e.g., inner ear problem that might effect balance; prior medical or surgical procedures effecting any part of your body; etc.) Heart Disease, Emphysema, Arthritis, or Stomach Disorders?
Describe the lighting conditions at the site of these tests.
Describe the noise level at the site of these tests.
Was there substantial road traffic in the vicinity? Yes No
What type of footwear were you wearing?
Was a designated, straight, physical line used to administer the walk-and-turn test or were you asked to walk an "imaginary line"?
Were the officer’s instructions clear? Yes No
Did the officer first demonstrate each test? Yes No
Were you first allowed to practice the tests? Yes No
Did the officer record the results as the tests were being administered? Yes No
Did anyone else witness these tests? Yes No
How do you think you did on each test?
Did the officer(s) tell you how you did? Yes No
How many hours had you worked (been awake) prior to the tests?
How much sleep had you had 24 hours prior to the tests?
Were you given a horizontal gaze nystagmus or HGN test?
Did the officer ask that you follow a moving object, such as a stick, a pen, a pencil or finger with your eyes?
If so, to the best of your recollection, what directions did the officer give you on how to perform the test?
If you wear eyeglasses or protective lens were you asked to remove them?
If you refused to take the HGN test, was anything told to you by the police concerning any ramifications or consequences of refusal?
Do you have a history of any neurological difficulties?
If you were involved in an accident, were either you or anyone else?
If so, give as much detail as possible about the nature and extent of the injuries to everyone involved.
Did the police in any way search either you or your vehicle? Were you asked to consent to a search? If so, what did you say? What do you recall about the search? What, if anything, did the police find and/or confiscate? Provide as much detail as possible.
Were you asked to blow into a hand-held device in the field? Yes No
Did the officer(s) tell you the results? If so, what were they?
Did the officer(s) ask you to "Describe your degree of impairment on a scale of one-to-ten? Yes No
If "Yes" to above, what was your response?
At the time you were stopped, did you consider yourself to be impaired to the slightest degree for reason of alcohol consumption? Why or why not?
Alcohol and food consumption prior to arrest:
Exact time of last drink
Quantity and Alcohol Type Time of previous drink
Quantity and Alcohol Type Time of previous drink
Quantity and Alcohol Type What time did you start drinking that day?
Total number of drinks that day?
Total number of drinks consumed in the hour before you were stopped?
What and when did you eat?
Were you asked to consent or submit to a chemical test (test of your blood, breath or urine)?
If so, what was your response?
Did you have any questions before making the decision whether to submit to the test(s)?
Did you ask any questions of the officer in this regard?
Do you recall whether any rights were read to you before submitting/consenting to the test(s)?
If you consented or submitted to the test(s), which tests were offered to you (blood, breath or urine), when were they offered, which tests were taken and what were the results of each test?
Where and when did you begin drinking?
What kind of beverage(s) were you drinking? How many drinks of each beverage did you have? What was the size of the glass or container from which you drank each beverage? Please provide as much detail as possible.
Provide the names and addresses of all persons who were with you while you were drinking or when you were stopped.
Do you believe that these persons would be willing to testify on your behalf?
What do you believe the witnesses would say about your drinking behavior, the amount of drinks you had, any interaction you had with other patrons, the police, drivers of other vehicles, etc.?
What were you wearing (clothing, shoes and jewelry) when you were arrested?
Were you neatly dressed?
Was there anything unusual about the way you were dressed or your appearance?
Did your clothing or shoes in any way restrict your movement or make it difficult for you to walk?
If so, explain in detail.
How do you feel the drinks affected your driving ability?
Did you consider yourself to be incapable of safely operating a motor vehicle?
Please explain in detail.
Did you drink any alcohol after your arrest?
If so, what did you drink and what were the reasons?
Were you photographed, videotaped or audiotaped? If so, were you told anything before being photographed, videotaped or audiotaped?
Were you read any rights prior to being photographed, videotaped or audiotaped? Did the officer ask your permission to photograph, videotape or audiotape you?
Were you allowed to see the photographs or the completed videotape?
Were you allowed to listen to the audiotape? If so, describe to the best of your ability what was contained in the photographs or videotapes, including anything of an unusual nature and what you recall hearing on the audiotape.
Was any foreign object in your mouth between the time of the arrest and the time of taking the test? (Gum, lozenge, mint, cough drop, candy, etc.) Yes No
Did you smoke cigarettes at any time between the arrest and to the time of the test? Yes No

Medical Information

Were you under the care of a doctor at the time of your arrest? If so, for what purposes?
Were you taking any medication? If so, state the kind of medication, the dosage, the frequency and the purpose. Include nonprescription medication (cough syrups, antihistamines, aspirin or ibuprofen) or any controlled substances (marijuana, cocaine, barbiturates, amphetamines).
Do you have any physical difficulties causing you to limp or to have poor balance?
Do you have any physical ailment or impediment that causes you to speak or communicate with difficulty? Do you have any physical ailment or impediment that causes you to breathe with difficulty? If so, explain.
Do you have any dental work, or have you used any denture adhesives which could absorb alcohol leading to a higher breath test result? Yes No
Do you have diabetes or heart diseases? Yes No
Have you ever suffered from any seizure disorder, including epilepsy? Yes No
Have you ever suffered from narcolepsy (sleepiness, drowsiness, etc.)? Yes No
Have you ever taken any anti-convulsant medication? If so, give details.
Do you recall having an upset stomach when you were arrested? Yes No
Do you recall belching or burping? (This can also affect the breath test.) Yes No
Do you wear eyeglasses or corrective lenses? Were you wearing them on the night of the arrest? Do you have a license restriction requiring eyeglasses or corrective lenses? If you were asked to submit to a field sobriety, coordination or horizontal gaze nystagmus test, were you wearing your corrective lenses?

Vehicle Information

What is the make, year, model, license number, serial number, color, and condition of your automobile?
What power equipment (power brakes, power steering, or automatic transmission) does it have?
Does it have any mechanical defects?
Do you have any trouble steering it?

Road and Weather Conditions

On what type of street were you driving (width, lanes of travel, pavement type, traffic signs or signals)?
What was its condition (smooth, rough, bumpy)?
What were the traffic conditions (light, moderate, heavy)?
What were the weather conditions (clear, rainy, snowy, drizzle, wet, dry)?

Rights Advisement

Were you advised that you had the right to refuse to submit to the chemical test or tests?
Were you told there were any consequences to your refusal? If so, what specifically do you recall being told about the consequences of refusal?
Were you advised that you could have a physician or other qualified person administer additional chemical tests?
Were you advised that you could have a physician or other qualified person administer a physical examination? If so, what do you recall about those advisements? What, if anything, did you do?
Were you advised that you could consult with an attorney prior to submitting to the chemical test or tests?
Were you advised that you could have an attorney present while you submitted to questioning, field sobriety tests, or the chemical tests? If so, what do you recall, and what happened? If you were given the opportunity to consult with an attorney, either in person or by phone, were you allowed a private area to discuss the case with him?
Were you given access to a telephone book to contact your physician or an attorney?
Were you given the names of any physicians or medical facilities willing to come to the police station and administer additional tests or a physical examination? If so, what happened? Give the names and addresses of any physicians, medical facilities or other persons who administered tests or performed examinations.
Were you advised that a sample of your blood, breath or urine could be retained for later analysis or retesting?
Were you advised that you would have to pay for any retention or analysis? If so, what was told to you and what did you do in response?
Did you request a sample of breath, blood or urine? Did you request that an additional test be taken? Provide as much detail as possible.

Prior Record

Do you have any prior drunk driving arrests or convictions? If so, when were they and what penalties, if any, were imposed? Were you represented by counsel? Please provide details including the police department that made the arrest, the court where the matter was disposed of or tried, and the name, address and telephone number of any attorney who represented you.
Do you have any prior arrests or convictions for any offense? Do you have a criminal record, either misdemeanor or felony? If so, provide the specifics of the charges and dispositions. Were you represented by counsel? Please provide for each offense the name of the police department, the court where the matter was disposed of or tried, and the name, address and telephone number of the attorney who represented you.
Have you ever been charged with any other administrative or traffic offenses which resulted in a license suspension? If so, provide as much detail as possible on the charging agency, the nature of the charge, the disposition and the administrative court or agency where disposition occurred. Do you have any other administrative or traffic violations currently pending? If so, provide as much detail as possible.
Are you on probation for any offense? If so, what is the offense, the terms of probation, the name, address and telephone number of your probation officer?

Alcohol Treatment and Counseling

Have you ever sought any alcohol, drug or substance abuse counseling? If so, please provide details including the name or names of counselor(s), the name and address of any rehabilitative facility and the dates of counseling or treatment.

2. Have you ever been required by any court or administrative agency to undergo alcohol, drug, substance abuse or psychological screening. If so, please provide details including the name and address of the court or administrative agency, the nature of the screening, the results of any evaluation, and the name and address of any facility that may have records of evaluation.

Do you presently feel or believe that you have a problem with alcohol or drugs or have a chemical dependency? If so, please explain what the problem is and how it affects you, your family and others who may have contact or dealings with you.
Do you wish to seek any counseling services or treatment with respect to any problem you are having with alcohol or drugs?
Do you have health insurance that may cover the cost of such treatment or counseling? If so, please provide details.

Insurance Information

Do you presently have automobile insurance? Did you have insurance at the time of your arrest? If so, provide the name of your insurance carrier, your policy number and any contact person (insurance agent or broker).
If you were involved in an accident that preceded the arrest and caused damage to your vehicle, to another driver's vehicle or that caused other property damage or physical injury, have you notified your insurance carrier? If so, when was the contact made and what was said about the accident?
If you were involved in an automobile accident, have you filed a motor vehicle accident report with local or state police or the registry of motor vehicles? If so, when was the report filed and have you retained a copy?

Miscellaneous

Is there any other information that has not been addressed or covered in this form that you feel is or might be important in the evaluation or defense of your case (Including the names of potential witnesses; the weather, wind, noise conditions that existed at the time field sobriety tests were administered; etc.)? If so, please explain.

DISCLAIMER: The foregoing is not to be construed as legal advice to or for any specific individual. Always seek the advice of counsel for specific legal problems.