Information Submission Form

In order to assess your chances of success at trial, please complete the following confidential questionnaire. Although not all questions may apply to your case, we do ask that you complete as many of the fields as possible to better help us understand your situation. (Fields marked with * indicated required information)

Once submitted, our office will contact you to setup a no obligation, confidential, no fee interview.

Our staff prides itself in expert handling of Criminal Driving offences.

Name:	*
Address:
Phone:
Cell:
Fax:
Email:	*
Marital Status:
Occupation:
Children:
Height:
Weight:
Gender:	Male Female
How would you like us to contact you:	Phone Fax Cell Email
What was the date of this occurence:
What time did you get up in the morning:
How much sleep did you get the night before this occurred:
What did you eat during the day:
If you were working during the day, what time did you finish work:
If you were not working, what were you doing:
Were you on any medication that day: (If yes, please provide details)
Did you take any illicit drugs that day: (If yes, please provide details)
Where were you when you had your first drink of alcohol:
What time was it when you had your first drink of alcohol:
What type of alcohol were you consuming on that occasion:
In what type of container or containers was the alcohol served:
When did you finish your last drink of alcohol:
What was the total amount of alcohol you consumed that day:
Were there other persons present while you were consuming alcohol:
If yes, how many:
Do you believe any of the persons present with you could confirm how much alcohol you consumed:
If you were consuming alcohol at a drinking establishment, how did you pay for the alcohol:
Did you keep any receipts:
If you were drinking at a private home, did you bring the alcohol or was it provided to you by your host:
If you brought alcohol, how much alcohol did you bring:
If pulled over by police, what was your destination:
If pulled over by police, did the police make any complaints about your driving (If yes, please provide details):
If you had an accident, briefly describe how the accident occurred:
What time were you pulled over by police or involved in the accident:
If there was an accident, approximately how long after the accident did the first police officer arrive:
If you were involved in an accident, were you in your vehicle or out of your vehicle when the first police officer arrived:
If you were in your motor vehicle, what portion of the vehicle were you in (driver's seat, passenger seat, back seat):
If involved in an accident, was it single motor vehicle or multi motor vehicle:
If you had an accident, were you, any of your passengers or any other parties injured:
If so, please give details of the injuries:
Were you asked to provide a breath sample into a roadside screening device:
If so, did the police officer have a roadside screening device with him or did he have to call for one to be brought to the scene:
If the officer had to call for one to be brought to the scene, approximately how long did it take for the device to be delivered:
If the roadside screening device had to be brought to the scene, were you advised of your right to speak to a lawyer while waiting for the screening device to arrive:
If so, what was your response:
If you advised police that you did wish to speak to a lawyer, were you given the opportunity to do so before you took the roadside screening test:
If you spoke to a lawyer before taking the roadside screening test, what means of communication did you use:
If you did speak to a lawyer before taking the roadside screening test, did you speak to a private lawyer or one that was provided by the police:
If you wanted to speak to a private lawyer, what assistance was provided to you by the police if any:
While speaking to the lawyer, were you given complete privacy:
Approximately how long did you speak with the lawyer:
Did you perform sobriety tests while at the roadside:
If so, which of the following tests did you perform:	A finger to the nose test Heel to toe walking test Balance test Cognitive test (eg. reciting the alphabet, counting backwards from 20, etc) Other (Please give details)
Were you asked by police if you consumed alcohol before you were arrested:
If so, what was your response:
Were you asked other questions by the officer before you were arrested:
If so, what were those questions:
How did you respond to those questions:
Information after arrest
Were you formally arrested by police:
Upon arrest, were you advised that you have the right to speak to a lawyer:
If so, how did you respond:
Upon arrest, were you given a formal demand to provide breath samples into a breathalyser/intoxilyzer:
Were you taken to a police detachment:
If so, approximately how long did it take for you to be transported there:
Once at the police detachment, were you given an opportunity to speak to a lawyer:
If so, did you speak to a lawyer:
If so, was it a private lawyer or a lawyer provided by the police:
If you wanted to speak to a private lawyer, what assistance was provided to you by the police, if any:
While speaking to the lawyer, were you given complete privacy:
Approximately how long did you speak with the lawyer:
How long after speaking with the lawyer were you turned over to the police officer who took your breath samples:
How many breath samples did you provide:
What were the readings:
If you are charged with refuse breath sample, did you make any attempt to provide breath samples:
If so, how many opportunities were you given by the police:
If you refused outright to provide breath samples, explain why:
Were you asked questions by the breathalyser technician:
If so, did you answer the questions:
Did you perform sobriety tests while at the police station:
If so, which of the following tests did you perform:	A finger to the nose test Heel to toe walking test Balance test Cognitive test (eg. reciting the alphabet, counting backwards from 20, etc) Other (Please give details)
What time were you released from the police station:
How were you able to get home from the police station:
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