Intake Form in English

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BASIC INFORMATION
NAME
ADDRESS

TELEPHONE NUMBER(S)

DATE OF BIRTH
CITY OF BIRTH
COUNTRY OF BIRTH
ALIEN REGISTRATION NUMBER/ WORK PERMIT NO. (A#)
DO YOU HAVE FAMILY MEMBERS IN THE UNITED STATES?
- Yes
- No
MARITAL STATUS
- SINGLE
- MARRIED
- DIVORCED
- WIDOW(ER)
INCOME AND TAX INFORMATION
HAVE YOU EVER RECEIVED PUBLIC ASSISTANCE?
- Yes
- No
WHAT IS YOUR INCOME…?
- WEEKLY
- BI-WEEKLY
- MONTHLY
LIST TYPE(S) OF ASSISTANCE:
HAVE YOU FILED INCOME TAXES EACH YEAR SINCE YOU ENTERED THE U.S.?
- Yes
- No
DO YOU CURRENTLY OWE ANY BACK TAXES?
- Yes
- No
IMMIGRATION HISTORY
DATE OF LAST ENTRY INTO THE U.S.
WHAT CITY DID YOU ENTER THROUGH?
WERE YOU INSPECTED BY AN IMMIGRATION OFFICIAL?
- Yes
- No
HAVE YOU EVER BEEN DEPORTED ?
- Yes
- No
DATE YOU WERE YOU DEPORTED
PLEASE EXPLAIN
ARE YOU CURRENTLY IN REMOVAL (DEPORTATION) PROCEEDINGS?
- Yes
- No
PLEASE EXPLAIN
LIST ALL PREVIOUS IMMIGRATION COURT DATES
LIST ALL FUTURE IMMIGRATION COURT DATES
HAVE YOU EVER REGISTERED FOR TPS?
- Yes
- No
DO YOU CURRENTLY HAVE A WORK PERMIT THROUGH TPS?
- Yes
- No
HAVE YOU EVER APPLIED FOR ASYLUM?
- Yes
- No
DATE OF APPLICATION
HAVE YOU EVER HAD ANY CONTACT OR PROBLEMS WITH IMMIGRATION?
- Yes
- No
PLEASE EXPLAIN
TRAVEL HISTORY
PLEASE PROVIDE THE FOLLOWING INFORMATION FOR EVERY TRIP YOU HAVE TAKEN OUTSIDE THE U.S.
DATE OF DEPARTURE
DATE OF RETURN
CITY/COUNTRY YOU TRAVELED TO
IN WHAT STATUS DID YOU RE-ENTER THE U.S.
DATE OF DEPARTURE
DATE OF RETURN
CITY/COUNTRY YOU TRAVELED TO
IN WHAT STATUS DID YOU RE-ENTER THE U.S.
DATE OF DEPARTURE
DATE OF RETURN
CITY/COUNTRY YOU TRAVELED TO
IN WHAT STATUS DID YOU RE-ENTER THE U.S.
DATE OF DEPARTURE
DATE OF RETURN
CITY/COUNTRY YOU TRAVELED TO
IN WHAT STATUS DID YOU RE-ENTER THE U.S.
DATE OF DEPARTURE
DATE OF RETURN
CITY/COUNTRY YOU TRAVELED TO
IN WHAT STATUS DID YOU RE-ENTER THE U.S.
CRIMINAL HISTORY
HAVE YOU EVER BEEN ARRESTED OR CHARGED WITH A CRIME IN ANY COUNTRY?
- Yes
- No
PLEASE LIST EACH ARREST, INCLUDING DATE, AND EXPLAIN
HAVE YOU EVER USED, TRAFFICKED, HELPED OR CONSPIRED WITH ANOTHER PERSON IN THE USE OR SALE OF DRUGS?
- Yes
- No
PLEASE EXPLAIN
HAVE YOU EVER BEEN INVOLVED WITH PROSTITUTION OR COMMERCIALIZED VICE?
- Yes
- No
FRAUD
HAVE YOU EVER USED FALSE IMMIGRATION DOCUMENTS?
- Yes
- No
HAVE YOU EVER LIED TO OBTAIN AN IMMIGRATION BENEFIT?
- Yes
- No
HAVE YOU EVER FALSELY CLAIMED TO BE A CITIZEN OF THE UNITED STATES?
- Yes
- No
IMPORTANT NOTICE

HAVING A CONSULTATION DOES NOT GUARANTEE THAT WE WILL ACCEPT YOUR CASE. DETERMINATION OF WHETHER WE WILL ACCEPT YOUR CASE FOR ONGOING SERVICE IS BASED ON PROGRAM QUALIFICATION AND A REVIEW OF ALL THE FACTS. THIS OCCURS DURING THE FIRST CONSULTATION.