Intake Form
***WE CURRENTLY HAVE 4 WEEK WAITING PERIOD*** 

Clean Slate Utah is a nonprofit organization, we are NOT lawyers and do NOT provide legal advice.

If you have any open cases, on probation or parole or unpaid fine or fees you will not qualify for record clearance. Please contact us again when all those have been resolved. 

If you have already filled out an intake form please DO NOT fill out another one and please email intake@cleanslateutah.org. 

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First Name *
Middle Name *
Last Name *
Date of Birth  *
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/
DD
/
YYYY
Primary Email Address *
Primary Phone Number  *
Street Address *
City  *
State  *
Country   *
Zip Code    *
County  *
Were you arrested under any other names, if so list them here. 
*please do not list n/a or nicknames 
 *
What is your race? *
What is your ethnicity? *
What mostly describes your gender? *
Have you ever (now or previously) identified as any of the following?

CHECK ALL THAT APPLY 
 *
Required
Has your record been a barrier in any of the following areas of your life? (Check all that apply) *
Required
Please share in more detail how your record has been a barrier in your life. 
Are you a parent of minor children? *
Are you employed? *
What is your annual HOUSEHOLD (including all adults in the household) income (before taxes)? *
How many people are in your household?  *
What is the main reason you are seeking to expunge your record?  *
Do you have a physical or mental condition that limits your ability to complete major life activities?  *
Do you have a physical or mental condition that limits your ability to complete major life activities?  *
Please rate your current mental health?    *
Have you experienced substance use disorder? *
Have you ever misused opioids  (opiates)?  *
Did your addiction start with prescription pills (opiates)?  *
Are you in recovery from substance use disorder?  *
How long have you been in recovery?
Is your criminal record related to substance use? *
Are you a currently working with Voc Rehab? *
Are you currently receiving any government benefits? (food stamps, unemployment, disability, etc.?) *
Do you have health insurance?  *
What is the highest level of education you have obtained? *
Which of the following best describes your CURRENT housing situation? (check all that apply) *
Which of the following best describes your NEXT FUTURE housing situation? (check all that apply) *
How many years has it been since your last charge on your record?  *
Please explain why you deserve an expungement and how you have since turned your life around?  *
How did you hear about us?  *
Required
Can we contact you in 6-12 months and see how your life has changed? *
Do you acknowledge that Clean Slate Utah is a nonprofit organization, we are NOT lawyers, we CANNOT represent you or give legal advice? *
Required
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