INTAKE FORM
Client's Last Name:
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Client's Name:
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Date of Birth:
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Address:
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Cell Phone:
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Home Phone:
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E-mail:
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SPOUSE/PARENT/GUARDIAN's Last Name:
Your answer
SPOUSE/PARENT/GUARDIAN's Name:
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SPOUSE/PARENT/GUARDIAN's Address:
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SPOUSE/PARENT/GUARDIAN's Cell Phone:
Your answer
SPOUSE/PARENT/GUARDIAN's Home Phone:
Your answer
SPOUSE/PARENT/GUARDIAN's E-mail:
Your answer
Have you ever been assigned an alien number?
If yes, please provide number:
Your answer
Immigration Status in the U.S.:
Your answer
Source of Referral:
Your answer
In what status did you last entered the U.S.:
Your answer
Place of Entry into the U.S.:
Your answer
Date you entered the U.S.
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DD
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YYYY
Number of times you have entered the U.S.:
Your answer
Date you entered the U.S.:
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DD
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YYYY
Were you arrested by USCIS?
Date:
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DD
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YYYY
Date:
MM
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DD
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YYYY
Date:
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YYYY
Date:
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From what countries are you a citizen of?
Your answer
Have you stayed continuously in the U.S. since last entrance:
Your answer
Have you ever been under removal, exclusion or deportation proceedings?
Have you ever requested voluntary departure from USCIS or judge?
Have you ever been the beneficiary of an immigrant petition?
If yes, who filed this petition?
Your answer
What is the priority date?
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Have you ever been a victim of a crime?
Have you ever been arrested, charged or convicted of a crime any where?
How many times have you been arrested?
Your answer
Date of Arrest
MM
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DD
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YYYY
City
Your answer
Charges:
Your answer
Completed
Your answer
Date of Arrest
MM
/
DD
/
YYYY
City:
Your answer
Charges:
Your answer
Completed:
Your answer
Date of Arrest
MM
/
DD
/
YYYY
City
Your answer
Charges:
Your answer
Completed:
Your answer
Date of Arrest
MM
/
DD
/
YYYY
City
Your answer
Charge:
Your answer
Completed:
Your answer
Have you ever used any aliases?
Your answer
Do you have any relatives in the U.S.?
Are any of your relative’s permanent residents or U.S. citizens?
If yes, who?
Your answer
If any of your U.S. citizen relatives are biological children please indicate their age(s) and health issues they may have:
Your answer
Have you ever submitted an application to USCIS?
If yes, state type of application:
Your answer
Was the application approved by USCIS?
Have you ever used a fraudulent travel document or submitted an application to USCIS or the U.S. embassy with information you knew was false to obtain a benefit?
If yes, please describe the document and when it was used:
Your answer
Have you ever been assaulted or burglarized?
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