Extreme Hardship Assessment Form
Please complete this form to provide a detailed assessment of extreme hardship factors affecting you or your family member.
Applicant's Full Name
*
First Name
Last Name
Applicant's Email Address
*
example@example.com
Applicant's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to the Person Experiencing Hardship
*
Please Select
Self
Spouse/Partner
Child
Parent
Sibling
Other
Country of Residence
*
Please Select
United States
Canada
Mexico
Other
Hardship Factors Assessment Matrix
*
Rows
Not at all
Mild
Moderate
Severe
Extreme
Financial Hardship (income loss, debt, inability to meet basic needs)
1
2
3
4
5
Emotional/Psychological Hardship (anxiety, depression, trauma)
6
7
8
9
10
Medical Hardship (health conditions, lack of access to care)
11
12
13
14
15
Educational Hardship (disruption to education, learning difficulties)
16
17
18
19
20
Safety/Personal Security (risk of harm, unsafe living conditions)
21
22
23
24
25
Family Separation/Disruption
26
27
28
29
30
Please describe the circumstances causing the hardship in detail.
*
How long has the hardship been ongoing?
*
Please Select
Less than 6 months
6-12 months
1-2 years
More than 2 years
What would be the likely consequences if the situation does not change?
*
Please upload any supporting documents or evidence (e.g., letters, medical records, financial statements).
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Please rate the overall impact of the hardship on daily life.
*
1
2
3
4
5
Submit Assessment
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