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 lquijano@nylpi.org
Email address
Your Name
Your answer
Organization
Your answer
Phone Number
Your answer
Which of the following describes this case?
Required
Client Name
Your answer
Client Phone number
Your answer
Client Email Address
Your answer
Client's Preferred language(s)
Your answer
Client Address (If your client is currently in detention please provide: Name and Address of the detention facility)
Your answer
Name of additional client contact (Family member, friend, community advocate)
Your answer
Phone number of additional client contact
Your answer
Email address of additional client contact
Your answer
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.
Your answer
Where is the client located?
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.)
Your answer
Please provide information about urgency such as upcoming court dates and deadlines.
Your answer
What type of medical advocacy is required?
Required
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.).
Your answer
Do you require a physician specialist? If yes, please mark one below.
If you require an additional physician specialist, please specify type of specialty below:
Your answer
Do you have signed HIPAA releases from your client?
Do you currently have copies of the client's medical records?
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).
Your answer
Additional Comments or Suggestions
Your answer
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