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General client information for
Seno and Associates
Please answer all questions to the best of your knowledge. Scroll down through
all categories. |
Name
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Address |
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City, State, ZIP
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Home Phone |
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Cell Phone |
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E-Mail |
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Married |
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Years
Spouse Name |
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Children |
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Age Child 1
Age Child 2 Age Child 3
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Drivers License Number |
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Social Security Number |
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Date of Birth |
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Current Employer |
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Employer Address |
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Employer Phone |
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Years Working |
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Position / Salary |
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Highest Education |
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Military Branch |
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Service Dates |
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Discharge Date |
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Referral |
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Physical / Mental Disabilities |
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Currently Under Medical Care |
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Alcohol Use |
Frequency
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Drug Use |
Frequency |
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Driving While Under The Influence
Of Alcohol (DUI-DWI) - Details |
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Court Location |
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Date
Room Time
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Date of Arrest |
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Arresting Agency |
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Time of Arrest |
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Arrest Location |
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Case Number |
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Charge |
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Case Number |
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Charge |
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Bail Bond Number |
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Amount
Deposit |
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Did Police Have Warrant? |
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What Was Probable Cause? |
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Items Seized |
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Witness #1
Name, Address, Phone |
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Background |
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Year
Offense Disposition
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Were you charged with anything else besides D.U.I. ?
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How many tickets received on date of arrest?
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Was your vehicle moving or stopped when you first noticed the
Police making contact with you?
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Keys in Ignition when stopped?
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If No, were keys in the car?
If Yes, were? |
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Was there an accident? |
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If Yes, was anyone injured?
If Yes, how badly injured?
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Did you admit to drinking any alcoholic beverages or ingesting
any drugs, either legal or illegal?
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If Yes, what was taken? How much? Over what period of time?
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Were any of the following test given to you at the scene or at
the Police station: |
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Say the alphabet? |
Result
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Stand on one leg? |
Result
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Walk the line? |
Result
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Pick up the coins? |
Result
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Finger to nose? |
Result
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Reverse counting? |
Result
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Portable breath test? |
Result
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Do you need to drive to / from / during the course of work / school / medical
care?
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If so, when and where?
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Do you believe that you were under the influence of alcohol or drugs at the time
of your arrest?
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Your Height |
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Your Weight |
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How Many Drinks |
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Kind of Drinks |
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Over What Time Period |
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Approximately how much time passed from your last drink to your
arrest time?
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Is it possible that there were drugs / medications in your
system?
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If Yes, what kind?
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If Yes, how much?
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If Yes, when were they ingested or taken?
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