SECURE INTAKE

Client Intake Form

Select your service tier below. The form will show only the fields required for your selection.

SECURITY: This form is transmitted over HTTPS. We collect only what is necessary to perform your selected service. All data is handled per our Privacy Policy.

Step 1 — Select Your Service

Choose a tier to see the relevant intake fields below.

Quick Scrub $99 Top 10 highest-risk data broker sites. Manual removal + verification. Requires: name, contact info, address

Deep Clean $199 21+ data broker and people-search sites. Full sweep. Requires: name, contact info, address

Full Dark $399 Deep Clean + facial recognition audit + social media & dating app hardening. Requires: name, contact info, address, social media, photos (via email)

Ghost Protocol $599 Everything. Full Dark + vehicle privacy + communication lockdown. Requires: all fields below

Standalone Add-Ons (optional — adds relevant sections below)

Vehicle Privacy Scan — $59 Facial Recognition Scan — $129 Dating App Privacy Scan — $49

Ongoing Monitoring (optional)

↑ Select a service tier above to continue ↑

Step 2 — Personal Information

Required

First Name *

Last Name *

Email Address *

Phone Number *

State of Residence *

Step 3 — Data Broker Removal Details

Required

Data brokers index you by name, address, and phone. The more you provide, the more listings we find.

Current Street Address *

City *

State *

ZIP *

Previous Addresses (helps find old listings)

Aliases / Former Names (maiden name, nicknames)

Date of Birth (helps narrow searches)

Additional Phones (old numbers)

Known Relatives (brokers link records to family)

Social Media & Dating Apps

Included in your tier

We'll audit privacy settings, delete dormant accounts, and submit data deletion requests. Only fill in what applies to you.

Facebook (if applicable)

Instagram (if applicable)

LinkedIn (if applicable)

X / Twitter (if applicable)

TikTok (if applicable)

Other Platforms (if applicable)

Dating Apps (current or former)

Device Type (for ad tracking opt-out)

Facial Recognition Audit

Included in your tier

We search 5 facial recognition databases for your face and submit opt-out requests where found.

PHOTO INSTRUCTIONS: Do NOT upload photos through this form. After submitting, email 3-5 clear face photos (different angles) to projectdarkscrub@proton.me with your name in the subject line. For opt-outs, we also need an anonymized ID scan — cover your name, address, and ID number. Leave only the photo visible.

I understand — I will email my photos separately after submitting this form.

Vehicle Privacy

Included in your tier

We check plate lookup sites, map nearby license plate readers, and audit connected car data sharing.

License Plate Number *

Plate State *

Vehicle Year / Make / Model (optional)

Connected Car Service (if any)

Primary Area of Travel (for ALPR camera mapping)

Your Situation

Optional but helpful

Helps us prioritize the right areas. Everything here is optional and strictly confidential.

Why are you seeking privacy services? (check all that apply)

General privacy — I want my data off the internet Stalking / harassment concern Domestic violence / safety situation Professional protection (executive, public figure, medical) Custody / legal dispute Identity theft prevention or recovery Other

Additional Context (anything else we should know)

✓ INTAKE SUBMITTED

Your email app should have opened with your intake details. Send the email to complete your submission.

If your email app didn't open, copy the form details and send them manually to projectdarkscrub@proton.me

If your service includes a facial recognition audit, remember to email your photos separately.

Client Intake Form

Step 1 — Select Your Service

Step 2 — Personal Information

Step 3 — Data Broker Removal Details

Social Media & Dating Apps

Facial Recognition Audit

Vehicle Privacy

Your Situation

Consent & Authorization

✓ INTAKE SUBMITTED