Criminal Intake

Hi, How Can We Help You?

Client*
DOB*
Date Format: MM slash DD slash YYYY
AKA*
SS*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Length of time at current residence*
Period of residence in VA*
Phone(H)*
(C)*
(W)*
Living with
Current Situation*
- Felony
- Misdemeanor
Date of Offense*
Date Format: MM slash DD slash YYYY
Arresting Officer*
Place of Offense*
Time of Offense*

: HH

MM
Custody Status*
Original Bond Amount & Terms*
Employer name*
Employer Phone*
Employer address
Length of time at present employment*
Education/Highest grade completed*
Degree/GED*
Military Service*
Discharge/Honorable or Other*
Court Date*
Date Format: MM slash DD slash YYYY
Circle: General District or Other
Total Fee Charged $*
Hourly Rate Quoted $*
Retainer Fee Requested $*
Medical History*
Psychiatric History*
Drug Use
- Yes
- No
Type & Frequency*
Alcohol Use
- Yes
- No
Frequency*
Prior Treatment
- Yes
- No
Where*
Other Charges Pending
- Yes
- No
If yes where*
Charge*
Prior Record
Charge Jurisdiction Date Disposition Probation or Parole
*Use back of sheet is addition space is required.
Clients Statements to Police about Present Charge(s): (Time, place, circumstances, custoday, persons present, warnings, records made, reason statements given)
Potential Defense Witnesses
Name Address Phone Contribution
Defendant's Account