Confidential Client Questionnaire Form Page 3
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Were you convicted? Court of Conviction
________________ Yes □ No □
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________________ Yes □ No □
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________________ Yes □ No □
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________________ Yes □ No □
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_______________________
________________ Yes □ No □
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_______________________
________________ Yes □ No □
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_______________________
________________ Yes □ No □
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_______________________
________________ Yes □ No □
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Other than the current charge(s), do you have any other charge(s) pending against you?
Yes □ No □ Maybe □
If yes, what is/are the charge(s), when did you get charged and where is/are the charge(s) pending?
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Are you currently on probation: Yes □ No □
Are you currently on parole: Yes □ No □
If yes to either probation or parole, list the conviction(s) that resulted in your probation or parole, when you were first
placed on probation or parole, and when you are scheduled to be released from probation and parole.
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Your arrest, even without a conviction, may result in a violation of your probation or parole. You are required to report
your arrest, or any new charges, to your probation officer or parole officer. Have you reported your arrest, or these
charges, to your probation or parole officer? Yes □ No □
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YOUR DRIVER’S LICENSE:
Certain drug and alcohol convictions can affect your ability to get or keep a driver’s license.
Do you currently have a valid driver’s license: Yes □ No □
Do you need a driver’s license for your job: Yes □ No □
List any moving violations or traffic tickets you have had, and the date of the violation/ticket:
Moving Violation/Ticket
Date
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