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NEW MATTER INTAKE SHEET

Name: ________________________________

PC Law #:__________________________

Address: ______________________________ _______________________________ _______________________________ E-mail Address: _________________________________ Driver’s License #: ______________________ Date of Birth: __________________________

Soc. Sec. #: _________________________

TELEPHONE NUMBERS Home: ________________________ Work: ________________________ Cell: _________________________ Fax: __________________________


EMPLOYMENT Occupation: _________________________ Employer: __________________________ Address: ___________________________ ___________________________

EDUCATION College ________________ Vocational ________________ High School __________________ Other:________________________________________________________________________ Military Service: _____________ Branch: _______________ Hon. Discharge: ______________

MATTER: ________________________v. ________________________ Description of Matter: ___________________________________________________________ Date of Offense: ____________________ Plaintiff: ______________________________________________________ Defendant: ____________________________________________________ Court: ________________________________________________________

CHARGE: ____________________________________________________________________ ____________________________________________________________________________

ARREST Date: _________________ Time: ________________ Place: ____________________________


Police Dept.: _________________________ Interrogated? _________ Refused Counsel? ___________ Appraised of Rights? ___________ Dexterity Tests Administered _____________________________________________________ _____________________________________________________________________________ Other Tests Administered________________________________________________________ Were any tests demanded by respondent and not given to them? __________________________ _____________________________________________________________________________ Previous Arrest: ______________________ Previous Conviction: ________________________ Probation: ____________________ Terms: __________________________________________

COURT AND BOND Arraignment __________________Court ______________________________________, MI Bond $__________ How long detained in jail prior to arraignment? _______________________________________

FACTS & CIRCUMSTANCES _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________


Food/Coffee, etc., consumed within 8 hours of arrest: __________________________________ ______________________________________________________________________________ Was Client Courteous? __________ If not, explain: ____________________________________ Condition of Speech _____________ Eyes _____________ Coordination __________________ Fumble for License ______________ Describe Clothing ________________________________ Passenger / Address_____________________________________________________________ Accident _______________________ Location _______________________________________

MEDICAL 1.

Was client under doctor’s treatment at time of accident? __________________________ If so, explain: ____________________________________________________________ ____________________________________________________________

2.

Was client using any medicines? ____________ If so, what kind? __________________________________________________________

3.

Is client a diabetic? ____________ If so, when was insulin taken prior to arrest? ______________

4.

Epilepsy ______________ Convulsions ______________ Dizziness ________________

5.

Any other illness or conditions? _____________________________________________ ________________________________________________________________________ OTHER

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________


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