Confidential Client Questionnaire Form (Page 2 of 3) in pdf

Alternate Contact Information:

Name of Contact Person if we cannot reach you: ______________________________________________________

Address: ____________________________________________________ County: __________________________

City: ______________________________ State: _________________ Zip: _____________

Phone Numbers: Home ________________________________ Cell _____________________________________

Work _____________________________ Relationship to You: ____________________________________

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Your Employment Information:

Current Employer:_______________________________________________________________________________

Employer’s Address ________________________________________________________________

City _______________________________ State _________________ Zip ______________

How long have you worked for this employer? ________________________________________________________

Gross Pay: $________________________ (Circle one:

Weekly / Bi-Weekly / Monthly)

What kind of work do you do? _____________________________________________________________________

How many people do you support with your income? ____________ # of adults _______________ # of children

List any professional or occupational licenses you have (e.g. plumbing license, CDL license): ___________________

__________________________________________________________________________________________

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Your Current Charges:

Charge(s) filed against you: _______________________________________________________________________

Court in which the charge(s) is/are filed: _____________________________________________________________

Yes □ No □

If yes, on what date were you arrested? ______________________

Were you arrested in this case?

Did you post a bond in this case? Yes □ No □

If yes, on what date did you post the bond? ____________________

How much bond did you post? ______________________________ Was you bond: Cash □ Surety □

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Your Criminal Record:

Whether you have a record, the kind of prior convictions, their date, and the type of offense can affect your sentence,

if you are convicted now. Your record can also affect the outcome of this case. A criminal conviction may have

occurred any time that you went to court and were fined, placed on probation, or sentenced to jail. The State has

access to your entire criminal record and it is important that I have that information as well so I am able to represent

you to the best of my ability.

Have you ever been charged or convicted, as a juvenile or adult, with a crime other than the current charge(s)?

Yes □ No □

If you have been charged or convicted of a crime before, please list every charge or conviction you have ever had, the

date of the charge or conviction and the court in which you were charged or convicted. Please include convictions in

other counties and states. Please include any juvenile cases, but mark them as juvenile offenses. Also include any

case which resulted in you participating in a deferral or diversion program, even if you successfully completed the

program or probation and the crime does not appear on your record.

Confidential Client Questionnaire Form Page 2