The Law Office of Gabrielle Bass

NEW CLIENTS

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Please fill out the fields below, or download our Client Intake Form.

Full Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

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Alternate Phone

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How did you hear about us?

Driver's License

Please indicate the State in which your License was issued.

Education

Occupation

Please include for how long.

Marital Status

If married, please include number of years married. If you have children, please list ages.

Point of Contact

Please include the following: Full Name Full Address Primary Phone/Alternate phone Relationship

Reference #1

Please include the following: Full Name Telephone Relationship

Reference #2

Please include the following: Full Name Telephone Relationship

Client Case Information

Charge(s):

Case Number(s)

Please include county.

Have you been to court on this matter?

If so, please include the following: What was the previous court date? When is the next court date?

Were you arrested?

Custody Status:

Location of incident:

Date of incident:

Was anyone else arrested?

If so, name(s) of all persons arrested:

Other names used:

Bail/Bond Amount:

Arresting Agency:

Arresting Officer:

Prior(s):

Probation/Parole?

Name & county of probation/parole officer?

Driving Under the Influence Cases ONLY

Has a DMV (admin per se) hearing been requested?

If yes, date of hearing:

If a DMV hearing was not requested within 10 days, would you like to request a hearing?

Did you take a chemical test?

If yes, B.A.C? Breath or Blood test?

Do you have prior DUI(s)?

If yes, year & county?

Were there any children in the car?

If yes, ages/relationship to you?

Get Started Today.

To set up a free consultation or if you have any questions,
contact us or give us a call at (626) 755-8773.

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