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Intake Questionnaire
Home
About Us
Criminal Defense
DUI & DWI Attorneys
Drug Offense
Domestic abuse misdemeanor & felony
Assault & Battery
Internet Crimes
Professional Disciplinary Actions
White Collar Criminal Defense
Juvenile Defense
Sex Crime Defense
State Charges
Expungement
Domestic Violence
Contact Us
Intake Questionnaire
Call Us
337-436-6262
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Intake Questionnaire
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Intake Questionnaire
Full Legal Name of Defendant:
Name of person filling out questionnaire if not defendant:
Address listed on driver's license
Alternate address (currently living):
Date of Birth
Social Security Number:
Drivers License Number/State?
Primary Phone Number:
Primary email address:
Date of Arrest/Summons/Ticket:
List of Charges arrested for/Summoned/ticketed:
Was defendant booked into jail and required to bond out?
*
Select
Yes
No
If so, what was the total bond amount?
If so, what is name of bonding agency?
Name of an alternate contact person:
Phone # of an alternate contact person:
Please provide brief details of your arrest/summons/investigation:
Do you have any prior criminal history? Please list arrests and convictions:
Are you a U.S. citizen?
Yes
No
Arrested for DWI ?
Select
Yes
No
What was the date of your arrest/citation?
In what parish were you arrested?
What law enforcement agency arrested or cited you?
What law enforcement agency arrested or cited you?
Is this your first DWI arrest?
Yes
No
If not, how many DWI arrests have you had?
How many DWI convictions do you have?
What are the approximate dates of your prior convictions?
Were you arrested and booked, or issued a summons and released?
Select
Arrested and Booked
Issued a Summons and Released
If booked, how long did you stay in jail?
Did the arresting officer seize your driver’s license?
Yes
No
Have you already requested an administrative hearing?
Select
Yes
No
Do you have a Commercial Driver's License?
Select
Yes
No
Do you drive a company vehicle for your employment?
Select
Yes
No
Do you drive a company vehicle for your employment?
Select
Yes
No
Where you involved in an auto accident when arrested?
Select
Yes
No
Were you involved in an auto accident when arrested?
Select
Yes
No
Did you blow in the intoxilyzer or submit to a blood draw?
Select
Intoxilyzer
Blood draw
What were the results if you blew in the intoxilyzer?
Where you taking any prescription medication at time of arrest?
Will a DWI conviction cost you your job? Please provide information regarding the nature of your employment.
How did you hear about Fred C. LeBleu III, Attorney at Law? Referral, Google, etc.
Submit
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