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Client Intake Form

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1-888-327-4652

California Expungement Evaluation

Confidential Attorney-Client Communication

Criminal Defense Partners
5670 Wilshire Blvd., Suite 1350
Los Angeles, CA 90036
(310) 860-5605
fax: (310) 860-5600
nshouse@shouselaw.com

EXPUNGEMENT CLIENT INTERVIEW FORM

Please provide as much information regarding your criminal offense as possible. Note: Fields with a * are required.

Name

Date

Address

(Number, street, city, and zip code)

Telephone:

(Home)
(Work)
(Cell)

Birthdate

- -

Social Security No.

- -

How Did You Learn About Our Practice?

* Email Address

TELL US WHAT HAPPENED:
THE ARREST: SEARCHES; STATEMENTS TO POLICE: Did anything unusual happen when you were arrested? Were you, anyone with you, or any place searched? Did the police take anything? Did you make a statement to the police?

Education

(Highest grade
completed)

(School name)

Vocational Training

(Skill)

(School name)

Driver's License No.

Auto Model/Make

Automobile License No.

Do you have any outstanding warrants for your arrest? Please give the details.

Is English your native language? If not, what is? Do you need an interpreter?
Are you a U.S. citizen? If not, what are your immigration status and the date of your most recent entry into the U.S.?

Do you have another case pending?

Are you now on probation or parole?

If you are on probation or parole, please list the officer or agent's name, address and telephone number.

Have you informed your probation officer or parole agent about this current charge(s)?

List all prior arrests and whether convicted or not.

Offense
Arresting Agency
Date
Disposition (What Happened)

Offense
Arresting Agency
Date
Disposition (What Happened)

Offense
Arresting Agency
Date
Disposition (What Happened)

Offense
Arresting Agency
Date
Disposition (What Happened)

Offense
Arresting Agency
Date
Disposition (What Happened)

FAMILY

Father
Name
Address
Telephone
Birthdate
Where Employed

Mother (Maiden)
Name
Address
Telephone
Birthdate
Where Employed

Stepfather
Name
Address
Telephone
Birthdate
Where Employed

Stepmother
Name
Address
Telephone
Birthdate
Where Employed

Brothers/Sisters
Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Children/Stepchildren
Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Name
Address
Telephone
Birthdate
Where Employed

Have you ever been referred to adult or juvenile probation or parole?

Agency	Location	Date

Have you ever been in a jail, prison, or mental hospital for juveniles or adults?

Name of Institution	Date	Why were you there?

MARITAL HISTORY

Married to:	Date Married	Date Separated/Divorced

(Spouse's current address/telephone)

(Spouse's current employer/telephone)

EMPLOYMENT HISTORY (List present or last employment first)

From/To
Name of Employer
Type of Business
(Position Held)
(Address)
(Telephone)

From/To
Name of Employer
Type of Business
(Position Held)
(Address)
(Telephone)

PLEASE DESCRIBE ANY CHURCH, CHARITY, CIVIC & COMMUNITY SERVICE INVOLVEMENT

LIST PERSONAL REFERENCES WITH COMPLETE MAILING ADDRESSES (Persons who know you other than relatives)

Name
Address
Telephone

Name
Address
Telephone

Name
Address
Telephone

Name
Address
Telephone

PHYSICAL, MENTAL, EMOTIONAL, MARITAL, DRUGS, AND/OR ALCOHOL PROBLEMS:
Do you have a problem in any of the above areas that has something to do with your case?
Yes No

If yes, please explain:

Are you currently under treatment or seeing a counselor?
Yes No

Name
Telephone

WITNESSES: Please list all the names, addresses, and telephone numbers of people who witnessed the alleged crime or who can give information about it.