Free Michigan DUI Evaluation

Please provide your name and a telephone number at a minimum. The remaining information on this page is optional but helps us evaluate your case. For example, the medical questions that we ask relate to some of the field sobriety tests, the accuracy of breath testing, and issues relating to blood testing. All information that you provide in connection with this intake form will be kept in complete and strict confidence.

                              GENERAL INFORMATION                              

Full Legal Name:





Zip Code:

*Main Phone:

Alternate Phone:

*E-mail Address:


What do you want to do with your case?

After you have entered your contact information, you can submit this form. We encourage you to complete the rest of this form so that we can accurately evaluate your case.

                              BACKGROUND INFORMATION                              

What is your age?

What is your gender?

Approximate weight on date of arrest?

How frequently do you drink alcohol?

What is your marital/family status?

What is your occupation?

Do you have a CDL?

Was your license valid on the date of arrest?

If your driver's license is from any state other than Michigan, please specify where you are licensed:

Is this your first arrest for DUI/DWI/Drunk Driving in your lifetime-anywhere?

Please list all prior DUI/DWI/Drunk Driving Arrests (even if dismissed) below, including year, city/state, and outcome (if known):

Are you currently on probation/parole for any reason?

     If "yes", for what offense(s):

                              CASE INFORMATION                              

Date of Arrest:

Time of Stop:

Time of Arrest:

City/Town/Municipality Where Arrest Occurred:

District/Circuit Court Number or Location:

Court Date:

Where were you stopped:

Why were you stopped according to the police officer?

Are there any witnesses who were with you before or during your driving that can testify for you?

Do you know if the officer recorded your driving on video?

Was there an accident?

Was anyone injured? (Check all that apply):

      No one was hurt
      Passenger in my vehicle
      Passenger in another vehicle
      Not Sure

                              FIELD SOBRIETY TESTING                              

Did you take any field sobriety tests?

Which tests were you given? (Check all that apply):

      Horizontal Gaze Nystagmus (eye test)
      Walk and Turn / Heel to Toe
      One Leg Stand
      Finger to nose
      Finger Count (1,2, 3, 4, 4, 3, 2, 1)
      Pick a Number
      Romberg (head tilt / eyes closed)

                              MEDICAL / PHYSIOLOGICAL                              

Please describe your overal state of health:

Were you under a doctors care on the date of your arrest?

Are you prescribed drugs or medications that you take on a regular basis?

     If "yes", please specify:

Do you have any prior injuries disabilities that might have affected your driving or performance of field sobriety tests?

     If "yes", please specify:

As to the following conditions, please check all that apply:

      Hypoglycemic or Hyperglycemic
      Dentures, Retainer, or Tongue Ring
      Glasses / Corrective Lenses
      Lazy Eye or Cross Eyed
      Blind in one eye
      Acid Reflux Disease (GERD)
      Take heartburn medication
      Esophageae hernia
      Ulcers / Problems with stomach
      Exposure to toluene, acetone, ether or other chemicals
      Use an inhaler
      Prior head injury
      Hearing aid
      Hearing loss
      Low carb diet / Atkins diet
      Back / Leg / Other Muscular Problems
      Ear infection (at or around time of arrest)
      High Blood Pressure
      Anxiety attacks
      Attention Deficit Disorder

                              CHEMICAL TESTS                              

Did you take a preliminary breath test on the scene?


Was there a breath test at the police station?


Was there a blood test taken?


If you refused to submit to a Datamaster and/or blood test, did the police officer serve you with a Notice of Refusal?

Did the police seek a search warrant to draw blood?

                              ADDITIONAL INFORMATION                              

Please provide us with any additional information you would like to share: