First Name(s)

Family Name

Country of Origin

Languages Spoken

English Language Fluent Proficient Basic None

Gender Female Male Other

Date of Birth Place of Birth Religion Ethnic Group Do you have a medical or psychological disability? Yes No

Educational Level No education Pre-primary Primary (grades 1-5) Lower secondary (grades 6-8) Higher secondary (grades 9-12) Short cycle higher Higher

Street Address 1

Street Address 2

City

State

Zip Code

Email

What is the name of the person we should call to set up an appointment? What is their phone number? Check all that apply

It is safe to call or leave voicemails at this number.

It is safe to send text messages to this number

Preferred Method of Communication Mail Email How did you find out about The Advocates?

Are you married? Yes No Do you have any children? Yes No Are you currently working? Yes No

Do you currently live with any immediate family members, including spouse, parent, child, brother/sister? Yes No

Do either you or your household have any other income sources, including public assistance, disability, and Social Security?

Other assets, such as a home, car, savings, and approximate value?

Have you ever been represented by another lawyer for your immigration case? Yes No Have you filed for asylum in the U.S.? Yes No Have you ever been to Immigration Court? Yes No

Are you an Afghan evacuee? Yes No What is your A#? (If you have not filed for asylum or have not been in contact with immigration, you may not have an A number.) On what date did you last come into the U.S? What was your place of entry? What is your current immigration status, if any? What is your I-94 card expiration date? (The white card given to you when you entered the U.S.) Have you ever been arrested by the immigration authorities in the U.S.? Yes No

Has anyone ever made/asked you do work or sexual acts that you did not want to do or that you felt you couldn’t quit, such as working at home, working for an employer, doing illegal work, engaging in sexual acts or anything else? Yes No If you were or are working, did you ever experience or witness threats or injuries at work? Yes No

Did anyone ever make you promises that turned out to be untrue (FOR EXAMPLE: promises about a job, promises about love, promises about a better life, promises of a loan that ended up changing)? Yes No Outside of detention, while in the US, did you ever live somewhere you felt was dirty, too cold/hot, unsafe, violent, monitored with cameras or other alarms, or restricted your movements unfairly? Yes No

Why are you afraid to go back to your country?

Why do you think you would be harmed?

Who do you fear will harm you or who has harmed you?

What, if anything, has happened to you and/or your family in the past?

When did the incident happen?

What do you think would happen if you did return to your country?