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New Client Information – Criminal Defense Case Form
Name
(Required)
First
Last
Mainden Name
Date
MM slash DD slash YYYY
Home Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Email
(Required)
Home Phone
Cell Phone
Work Phone
Birth date
MM slash DD slash YYYY
Social Security Number
Drivers License Number
What is the best way to communicate with you?
Mail
Email
Phone
May we contact you at home?
Yes
No
Alternate Number
Employed by
Occupation
Work Address
Date of Hire
MM slash DD slash YYYY
Gross Pay
Net Pay
Criminal Case Information
Case No.
County
Court Date
MM slash DD slash YYYY
Court Time
Hours
:
Minutes
AM
PM
AM/PM
Current Criminal Charges
Date Arrested
MM slash DD slash YYYY
Bond
Did you make statements to law enforcement?
Yes
No
if yes, your statement
Prior convictions/charges
Are you on probation or court supervision?
Yes
No
If so, please list county and termination date
Are there any related court cases?
Yes
No
Is DCFS involved?
Yes
No
Do you have any special physical or mental health problems?
Yes
No
If so, describe
Do You Support Dependents?
Yes
No
If so, How Many?
Referral Information
Who referred you to our office (or how did you hear about us)?
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