Consent for an Immigration Evaluation
Capacity Sharing LCSW PLLC / Alifa Evaluation · Alif Ahmed, MS, LCSW · alifaeval.com
Please read this with your clinician before you begin.
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Consent for an Immigration Evaluation
What this is. We will meet and talk about your life, your health, and what has happened to you. I will write a report for an immigration case.

This is not therapy. I am not your therapist, and this is not treatment. My job is to give an honest, independent professional opinion.

Who will see it. Your lawyer receives the report. Your lawyer may file it with immigration or with the court. Because of that, what you tell me is not private the way therapy is private.

Two things I must act on by law. If someone is in serious danger of being hurt, or if a child or a vulnerable adult is being abused.

You are in charge. You can skip any question, ask for a break, or stop at any time. Some questions ask about hard experiences.

Records and cost. We keep your answers in your file. Fees are what we agreed.

Questions. Ask me anything, at any time. You can keep a copy of this form.
Do you agree to take part in this evaluation? *
Your full name *
Typing your name here is your signature.
Today’s date *
MM
/
DD
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YYYY
In this case, who are you? *
This tells your clinician who is being evaluated today.
If you are being evaluated for someone else’s case, what is that person’s name?
Which case is this evaluation for? *
Your email
Optional. If you enter it, you will receive a copy.
Clinician’s name (the person meeting with you today) *
How was this consent read?
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If an interpreter was used, language and interpreter’s name
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