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Category: Careers
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December 12, 2022
Breathalyzer Case Inquiry Form
Breathalyzer Case Inquiry Form
Defendant Name
(Required)
First
Last
Date of Birth
MM slash DD slash YYYY
Contact person (if you are not defendant)
Defendant Phone Number
(Required)
Defendant Email Address
Defendant Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Docket Number
Court where case was resolved
Are you on probation?
Select
Yes
No
Plea or Trial attorney name
Client comments or concerns
How many people live in your household?
Do you receive Transitional Aid to families with Dependent Children(TAFDC)?
Select
Yes
No
Do you receive Emergency Aid to the Elderly, Disabled or Children(EAEDC)?
Select
Yes
No
Do you receive Massachusetts Veterans Benefits Programs?
Select
Yes
No
Do you receive Medicaid (MassHealth), Supplemental Security Income(SSI)?
Select
Yes
No
Are you currently employed full-time?
Select
Yes
No
Were you represented by court-appointed counsel within the last three years (in your OUI or any other matter)?
Select
Yes
No
Drug Lab Case Inquiry Form
Defendant Name
(Required)
First
Last
Date of Birth
MM slash DD slash YYYY
Contact person (if you are not defendant)
Defendant Phone Number
(Required)
Defendant Email Address
Defendant Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Docket Number
Court where case was resolved
Are you on probation?
Select
Yes
No
Client comments or concerns
GPS Monitoring Inquiry Form
Your Name
(Required)
First
Last
Contact Telephone Number
(Required)
Contact Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Contact Email Address
(Required)
Criminal Case Number
Court in Which Your Case Was Decided
Name of Attorney Who Previously Represented You in Your Case
Court of Supervision
What is Your Present Source of Income?
MH Hospital Admission Contact Form
"
*
" indicates required fields
Name
This field is for validation purposes and should be left unchanged.
What is your full name?
*
What is your date of birth?
*
Month
Day
Year
What telephone number should we use to call you back?
*
What is your cell phone number? (If other than above)
What is your email address?
Are you contacting us about yourself, a friend or a relative?
Please select...
Self
Friend
Relative
Are you a patient in a hospital receiving treatment, or waiting in an emergency room now?
Please select...
Yes
No
Facility name
When did you arrive at the hospital or emergency room?
What legal problem are you contacting us about today?
*
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