Criminal Charge Intake Form

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

DOB *

Age at time of offense *

SSN

Driver's License Number *

State Licensed *

Emergency Contact Info

Emergency Contact Phone

Contact Permitted

Prior Criminal Charges

Charges Against You

Reason For Police Stop

Next Court Date

County

Are You Currently on Probation or Parole?

Admissions by Client

Are the any Co-Defendants? If YES, please provide their contact information:

Are there any witnesses to the crimes you have been charged with? If YES, please provide their names and contact information:

How did you hear about us?

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