Attorney Refferal

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Attorney Information

First Name

Last Name

Law Firm

Best phone number to reach you at:

Text

Call

E-mail address:

Brief Summary of the case:

Type of Evaluation:

Extreme Hardship Waiver

Asylum

VAWA

T-Visa

U- Visa

Other

Date psychological evaluation is needed by:

Evaluation will be completed within 2-4 weeks. A rush fee of $300 is added if a report is needed within 10 days following the second scheduled interview.

Would you like to schedule a call prior to having me contacting the client?

Yes

If yes, let me know if you prefer e-mail or call. If a call is best let me know what days and times work best.

Client Information:

Client First Name

Client Last Name

Client Phone Number:

Client E-mail address:

Primary Language Spoken:

Is an interpreter needed?

Yes

Additional information that is helpful to know:

Thank you for completing this information form. I will be in contact with you within 24 hours of receipt M-F. I look forward to working with you!

Your information will be encrypted.

Sarah Dinan MS, LPC, CCTP-2

I am a Licensed Professional Counselor in PA who is trained in conducting Immigration Psychological Evaluations. I have been conducting clinical evaluations since 2007, specializing in working with trauma and domestic violence victims.

Telephone 610-504-7776
www.mentalhealthcounselingofnazareth.com
25 E Center St, Nazareth, PA, 18064, United States

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