Client Referral

This is to be completed by the individual seeking a clinical evaluation.

Please correct the errors described below.

Client Information

First Name

Last Name

Best phone number to reach you at:

Text

Call

E-mail address:

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.

Primary Language Spoken:

Is an interpreter needed? **To ensure an impartial evaluation is conducted, family members are not permitted to serve as an interpreters. Interpreter costs are separate from evaluation costs, and will be the client's responsibility.

Yes

Attorney Information

Do you have an attorney?

Yes

If yes, please complete the following information:

Attorney First Name:

Attorney Last Name:

Attorney Phone Number:

Attorney E-mail Address:

Name of law firm

Law Firm website:

Thank you for completing this information form. I will be in contact with you via e-mail within 24 hours of receipt Monday-Friday. I look forward to working with you and taking the next steps.

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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