Immigration Assistance Request

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Client First Name: *

Client Last Name: *

Client's Date of Birth: *

YYYY

Client Address: *

Client A Number: *

Number assigned to an individual by immigration.

Client Phone Number:

Client Email Address:

Client Language Needs: *

English

Spanish

Other:

Required

Criminal Cause Number(s): *

Current Charge(s): *

Court where case is filed: *

Priors (Please list date of arrest, offense, and disposition, including any sentence imposed and any suspension): *

Please include any interactions with law enforcement even if it did not result in arrest.

Custody Status? *

Out

Immigration (ICE) Hold? *

Yes

Next Setting *

YYYY

Immigration Status: *

Lawful Permanent Resident/ Greencard Holder

Refugee/Asylee

Entered with visa

Entered without documentation

Check all that apply *

Client has previously been removed

Client has previously been deported

Client has previously been denied admission

Client has previously been set for immigration court

Client has previously spoken to an immigration officer

None of the above

Required

If yes to any of the above, when did action take place

Date of Entry into US *

Check which applies to client's spouse or partner *

US Citizen

Lawful Permanent Resident

Undocumented

Other:

Required

Please list ages and immigration status of client's children *

Are either of client's parents *

a US Citizen

a Lawful Permant Resident

Undocumented

Other:

Are any of client's grandparents or siblings US citizens? *

yes

Please list name and phone number of closest relative that client authorizes immigration attorney to contact *

Please check all that apply *

High school enrollment

High school diploma

GED

Client filed for immigration relief in the past

Client was previously victim of a crime and reported it to police

Client fears return to home country/has suffered past persecution

Client has been a victim of domestic violence or trafficking

None of the above

Required

Client's goals re: Immigration Consequences (check all that apply) *

Avoid conviction that triggers deportation

Get out of jail ASAP (regardless of potential immigration consequences)

Preserve eligibility to obtain future LPR status or citizenship

Keep lawful status and stay in the US

Immigration consequences, including deportation are not a priority

Other

Required

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