2026 Expunction & Supportive Services Resource Clinic Intake Form

2026 Expunction & Supportive Services Resource Clinic Intake Form

Please complete all fields below for walk-in registration. Use N/A where applicable.
Name

First NameLast Name
Names you have used in the past (If no other names, write NA)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address (Street address, city, state, and zip)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Media Handles (Please list your social media handles for all social media platforms. N/A if none.)
Household Size (Including yourself, how many people live in your home)
Monthly Income (Including income from all sources for all household members)
Texas Counties where you have criminal history for review
The information provided is a true and accurate statement of my financial situation (including the income of all family members with whom I reside) and the facts concerning my problem.
I confirm that I am the person requesting legal services and that this application is not being completed by someone on my behalf.
I confirm that everything submitted and stated within this application is true.
Signature
Should be Empty: