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AsylumWorks Waitlist Questionnaire
Welcome!

Please fill out the following questionnaire to become a client at AsylumWorks to access all of our free services. You will be asked 18 questions to help us better understand you and your current situation. Your answers will also help us to connect you with an AsylumWorks Health and Wellness staff member who is a good match for you.

To be eligible for AsylumWorks services, applicants must:

● Be unable to return to their home country because of safety concerns;
● Currently live the Washington, DC metro area (including parts of Maryland and Virginia);

AND

● Have submitted paperwork to apply for an immigration status such as asylum
OR
● Are able and interested in filing for humanitarian-based legal protection.

Once you submit this questionnaire, you will see a confirmation page that details the next steps and what to expect when we reach out to you.
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Email *
First Name *
Last Name *
Phone Number *
What is your gender identity? *
What country are you from? 

We ask this so that if needed, we can connect you with a staff member who speaks your dialect and is otherwise a good fit.
 *
When did you arrive in the U.S.? 

If you have visited the U.S. multiple times, we only need your most recent date of arrival.
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How did you hear about AsylumWorks?

We use this information to better understand how people hear about us.
 *
Required
What is your sexual orientation? *
How well do you speak and read English? *
What language do you prefer to receive services in? *
What county or city do you currently live in? *
What is your immigration status? *
Have you applied for asylum? *
Do you have children under 18? *
Are you a member of the LGBTQ community (lesbian, gay, bisexual, transgender, or queer)? *
Do you have relatives or friends in the area? *
Do you or someone in your household have any serious health concerns? *
What is your race? *
What is your ethnicity/ethnic group? 

We ask this because it is required by our funders. Your personal information including your name and other identified information will not be shared.
 *

Were you mentally or physically harmed by someone representing the government (police officer, soldier, prison guard, government employee, etc.) in your home country?

OR

Were you mentally or physically harmed by an individual, or group of individuals in your home country, and government officials did not or would not offer you protection? 

We ask this because AsylumWorks has special resources to support survivors of torture.

 *
What is your current employment status?
 *
Do you have any other details you would like us to know?
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