Client Portal OVI Part 2 intake form

Full name*

In the field above you can enter either your name or a nickname you prefer to go by.

Nature of the charges*

Select all that apply:

Date of Arrest / Citation / Incident*

Did you take a breath, blood or urine test?*

What was the result, if you know?

* For the next two questions do not include current charge.

Number of prior OVIs / DUIs in the last 10 years?*

Number of prior OVIs / DUIs lifetime:*

Prior Court Date - if any

Step 2: Contact and Client Information

Additional contact number:

Addtional email address?

Best phone number, during the evening, if different:

What type of number is this?*

Best times to call:

Is there any other person authorized to contact? If so, enter their best phone number:

What type of number is this?*

What's the name of your employer?

What is your job, occupation or position?

Enter your home address:

Street Address City State ZIP Code

Age:

Date of birth:

Social Security #:

Drivers license number:

Drivers license state.

If you do not have an Ohio Drivers license what is the issuing state?

Is the license valid?

Yes
No

If your ODL isn't valid, what's the reason?

Do you have car insurance?

Yes
No

If so, what's your insurance company's name?

Showed proof?

Yes
No

Step 3: Professional Licenses Information

If you hold a CDL license or a Professional License – or hope to obtain one- in is urgent that we know about it. Please check the appropriate boxes below

Please check the appropriate boxes below:

Are you currently a student?

Yes
No

Do you get / hope to get loans or grants or financial aid?

Yes
No

Any other licenses or certificates?

Please describe any other license or certificate you might have that may be affected by a DUI conviction

Do you ever travel to Canada or other countries?

Yes
No

Are you a US Citizen?

Yes
No

If no, describe your status:

Step 4: Details of the Stop

Date of the arrest?

Time of the arrest?

Location (city / closest city)

Street / Route Number

Nearest Cross Street / Exit

List the Charges written on the Traffic Ticket and/or Compliant

Click the (+) to create a new line in this list.

Name of Charge	Statute / Code Number

Arresting Agency:

Arresting Officer's Name

Reason For Stop or contact

Look on the BMV 2255 Form

This is the Yellow-Gold Form – In B, what does the officer list after "my reasonable grounds for OVI arrest before test were?" Note: the officer's handwriting and abbreviations are often hard to understand, below write what you think it says:

Step 5: Field Sobriety Test Details

Field Sobriety Tests Requested?

Yes
No

Any done / attempted?

Yes
No

Location - check all that apply

At the Scene
At the Police Station / Patrol Post

HGN – Did you take an eye test?

Yes
No

During this test were you standing or sitting?

Standing
Sitting

Did you complete the eye test?

Yes
No

Were there any problems? If so, write them here:

Was a walk & turn test requested?

Yes
No

If requested, select which applies:

Completed
Refused
Stopped

How did you do?

Pretty Good
Average
Not Good

Was a one leg stand test requested?

Yes
No

If requested, select which applies:

Completed
Refused
Stopped

How did you do?

Pretty Good
Average
Not Good

List any other sobriety test given:

Examples include: alphabet, partial alphabet, finger to nose etc. To create another line on the list, click the (+).

Other Sobriety Test	How did you do?

If you were read your rights, where?

Signed Rights Form?

Yes
No

Step 6: Questions and Admissions

What was your response to "have you been drinking?" or other potentially incriminating answers / statements.

Did you make any admissions while in car? If so, write them here:

Did you make any LATER admissions? If so, WHAT did you say and WHERE, write them here:

Did you do jail time?

Yes
No

Enter the dates of your jail time:

Was your vehicle impounded?

Yes
No

Enter the date it was released:

Step 7: Chemical Test Details

Roadside Breath Test requested?

Yes
No

Did you take the test?

Yes
No

If so, what were the results?

Which test was requested at the Police Station?

Check all the tests that were requested.

Blood test
Breath test
Urine test

Did you ask to talk to an attorney before deciding whether to take the test?

Yes
No

Were you offered a chance to call an attorney before the test?

Yes
No

Did you TRY to contact an attorney before the test?

Yes
No

If so, who?

Did you talk to an attorney before the test?

Yes
No

If so, who?

Did you talk to ANYONE before the test?

Yes
No

If so, who?

If you submitted to ANY tests, enter them below:

If you refused to ANY tests, enter them below:

If you refused, did you give any reason(s)?

Yes
No

What reasons did you give?

Step 8: Test Results

Results of the tests you took.

Were you given a printout of breath results?

Yes
No

Did they request a urine or blood test?

Check all that apply.

Urine test
Blood test

Location

What was the name of the testing officer?

Attempts

Did you receive a test w/ printed results?

Yes
No

What was the result of the traffic ticket?

Test 1

Time	Result	If no result, the reason:

Test 2

Time	Result	If no result, the reason:

If more tests / attempts please list same info for each below:

Step 9: Witnesses

Please list any friends or acquaintances that may be a witness to your case.

Enter their name(s) and relationship to you below. Click the (+) to add more people.

Name	Relationship

Type of witness:

Enter when your witnesses were with you.

Step 10: Prior DUI arrests and/or convictions

You're almost to the end. Just a few more questions to help us evaluate your case.

Number of prior DUI CONVICTIONS, if any:

Number of prior DUI ARRESTS, if any:

List the following details for any Prior DUI Arrests / Charges and Case results

Click the (+) to create a new line in the list.

Approx Date m/y	Ct.	Convicted-Y/N	Trial –Y/N	Plea to

Prior Refusals to take a Chemical test

If you have ever been asked by an officer to take a chemical test it may affect the length of your license suspension – please provide these details:

No. of Prior Refusals:

Enter details below year(s) of each refusal:

Click the (+) to add another year in the list

Year	Result in Susp?	DUI plea?	Actual ALS Hrg. Held?

Traffic Tickets in last two years – we want to see if "points" are an issue:

Click the (+) to add another year in the list

Year	Charge	Result

Traffic Cases requiring a Court Appearance in last 10 years (Not speeding, or minor tickets)

Click the (+) to add another year in the list

Year	Charge	Result

Past Criminal Cases – list all felonies ever & all misdemeanors in 10 years

Click the (+) to add another year in the list

Year	Charge	Result

Step 11: How did you find us?

Please Note: We reward our clients who learned about us via a former client, another lawyer or via a web site (we are listed on several) and provide us with details about the source

Were you referred by another person, lawyer or law firm?

Yes
No

If you were referred to us by another person, what was their name?

We would like to send them a nice thank you note.

If you found us online...

If you found us via the Internet please tell us what website or search engine you found us on.

If you checked other please specify where you found us.

Name

This field is for validation purposes and should be left unchanged.