New York Lawyers for the Public Interest Immigration Detention Referral Form
If you have a client who is currently in need of medical advocacy, please complete this form and notify Lauren Quijano via email at
Which of the following describes this case?
Client is currently in removal proceedings
Client is currently being held in an immigration detention facility
Client was recently released from an immigration detention facility
Client Phone number
Client Email Address
Client's Preferred language(s)
Client Address (If your client is currently in detention please provide: Name and Address of the detention facility)
Name of additional client contact (Family member, friend, community advocate)
Phone number of additional client contact
Email address of additional client contact
Are there any community organizations or local groups who are supporting your client with larger advocacy?
Please list the names of organizations or local groups that are supporting your client.
Where is the client located?
New York Facility
New Jersey Facility
Facility in another state
Client is no longer being held in a facility
Please provide a brief summary of your client's legal case (Ex 1: Asylum case. Need to confirm prior medical history. Ex 2: Humanitarian Deferred Action. Need to prove medical needs/hardship.)
Please provide information about urgency such as upcoming court dates and deadlines.
What type of medical advocacy is required?
Volunteer physician to review medical records
Volunteer physician to provide a medical affidavit or medical advocacy letter
Volunteer physician to provide testimony for an upcoming hearing
Please provide brief summary of your client's medical history and current medical needs. (i.e. specific diagnosis, medications needed, frequency of medical appointments/testing.).
Do you require a physician specialist? If yes, please mark one below.
Obstetrics & Gynecology
Otolaryngology / Head & Neck Surgery
Pathology: Surgical & Anatomic
Plastic & Reconstructive Surgery
If you require an additional physician specialist, please specify type of specialty below:
Do you have signed HIPAA releases from your client?
Do you currently have copies of the client's medical records?
Records have been requested but not received
If you have not requested medical records, please provide the contact information for your client's doctors (i.e. MD Name/Phone#/Address or Hospital).
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