General Information Form

Today's Date

Name

First

Last

Email

How did you hear about Mimi Coffey?

Social Security Number (last 4 digits):

DOB:

Driver's License #:

Driver License State:

documents. contacts? you

Phone

Home Phone:

Work Phone:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Preferred method of communication:

***ALL COURT NOTICES FROM OUR OFFICE ARE SENT VIA EMAIL

Emergency Contact Phone Number:

Emergency Contact Email:

Date of Arrest:

County of Arrest:

Arresting Agency?

What type of sample did you provide?

Are you a U.S citizen?

Do you have a CDL?

Were you ordered to install a ignition interlock device/INHOME breathalyzer as a condition of bond?

Military - Active or Reserve Duty:

Veteran:

Current Student?

Year/Make/Model of Vehicle:

Place of Employment:

Length of Employment:

Occupation:

Employer Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

***If there is anyone you would like to authorize to receive information regarding your case should they contact our offices, please list below:

Name:

Cell Phone:

Email:

Bonding Company (if you posted a cash bond, type "CASH"):

Please list all current criminal charges:

Please list all prior criminal history including charge and years

Briefly describe events leading to arrest (Why were you stopped):

What did you say and what did they say to you? What questions were you asked? (please be as detailed as possible):

Were you read your rights? If yes, when?

Were you involved in an accident?

Was there another vehicle involved in your arrest? If yes, what conversations did you have with the other driver or passengers?:

Did you have any passengers in your vehicle?

Were you or your vehicle searched?

Which field sobriety tests were you perform?

Do you believe you were under the influence of alcohol at the time of your arrest?

List all alcohol and food consumption prior to arrest including time consumed:

Where were you drinking?

Were you on any prescribed medications at time of the arrest? If yes, please list:

Had you taken any over the counter medications prior to the arrest? If yes, please list:

Do you have any injuries that would prevent you from completing field sobriety tests?

Do you wear glasses or contacts? If yes, were you wearing them at the time of the arrest?:

Briefly describe the weather conditions at the time of the arrest:

Were you advised of your right to refuse any tests? (breath, blood, field sobriety):

Were you advised of your right to contact an attorney prior to deciding to take any tests?

Please describe your sleep the week/days leading up to your arrest (normal, deprive, etc.):

Is there anything else you would like to say about this arrest/charge?

Please upload any relevant case documents. (i.e. documents received upon release from jail)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

***ALL COURT NOTICES FROM OUR OFFICE ARE SENT VIA EMAIL

***If there is anyone you would like to authorize to receive information regarding your case should they contact our offices, please list below:

Compassion, Honesty and Expertise.

DWI Defense

Testimonials

Q & A

Contact Us

817-831-3100

mimi@mimicoffey.com

Request FREE Consultation