Background Information Intake for Immigration Clients

Legal Server Number

Date of Intake

Date

Name

Birth Date

MonthDayYear

Phone

Area CodePhone Number

Secondary Phone Number

Area CodePhone Number

Physical Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Mailing Address:

Same as physical addressOther

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

example@example.com

Gender Identity

Primary Language

English Ability

PoorFairGood

Are you currently being represented by an attorney?

YesNo

Ethnicity

Hispanic or LatinoNon-Hispanic or Latino

Race

Hair Color

Eye Color

Height:

Weight

How did you hear about us?

Marital Status:

Date of Marriage:

MonthDayYear

Spouse Immigration Status:

Do you have any children?

YesNo

If yes, DOB/Ages, immigration status of children

Client Immigration status in the U.S.

Client Country of Birth

Client's Country of Citizenship:

Is/was either of your parents a U.S. Citizen or Legal Permanent Resident?

YesNo

If U.S. Citizen, how?

If applicable, date of Naturalization

Date

Were either of your grandparents U.S. citizens when your parents were born?

YesNo

Do you have a spouse, parent, or child who is active duty in the U.S. Armed forces?

YesNo

Has anyone every filed a petition with immigration for you or your parents?

YesNo

If YES, was it before 04/30/2001

YesNo

Do you have an A#?

YesNo

If yes, Enter A#:

Name of Staff/Advocate completing intake:

First NameLast Name

Language(s) spoken during intake:

Interpretation used:

YesNo

Voiance/ Phone interpretation serviceOther interpreter

Voiance Number

Other interpreter used

Documents Reviewed (check all that apply)

Attestation Regarding StatusRetainerMediation DisclosureMedia Consent

Intake Notes if any:

Background Information Intake for Immigration Clients

Participants Information

Intake Worker Information