Referral form

Contact Michelle at:

Call/text: 781-226-1606
Email: mcollins@mlbcollins.com
Website: www.mlbcollins.com

Name of person making referral

Law firm

Email address

Phone number

Attorney name/firm

Client information

Client name

Client’s date of birth

Client mailing address

Client email address

Client phone number

specify

Is client able to communicate in English to arrange details for the evaluation?

yes no

Is the client prepared to make initial scheduling arrangements with using Google translate over text/email or does client have someone who can assist with interpreting a phone call?

Does client have access to Zoom and a private place to meet with adequate wifi?

yes no need to check

Please note that in-person evaluations can be arranged near Wakefield, MA for an added fee to cover meeting space rental fees.

Please note that the client will need to be located in Massachusetts or Vermont at the time of the evaluation, due to licensing requirements.

When do you need the written evaluation completed?

If Asylum:

Client’s country of origin

Hearing date, if known

Do you anticipate wanting testimony from Michelle?

yes no unsure

What group is the basis of the application?

race

religion

nationality

membership in a social group

political opinion

Please specify

Are there issues with the one-year filing deadline?

yes no

If no: Please comment

Has the client completed their declaration? (please note that a draft of the declaration is needed prior to starting the evaluation and the final declaration is desired prior to finalizing the written evaluation)

yes no

Please upload the client's draft declaration/any other relevant documentation/medical records, if available

Add file

Please upload a file

Please provide a brief overview of the persecution your client experienced and how you hope this evaluation will support their application for asylum

If Hardship/Cancellation of Removal:

Client’s country of origin

specify

Please share any details you know about why this waiver is needed

Please share any information you have regarding why you expect there may be grounds for hardship

If VAWA:

Client’s country of origin

Please provide a brief overview of why this client is eligible for relief under VAWA

If U Visa:

Client’s country of origin

What was the nature of the crime committed against the client?

Is a police report available for review?

yes no can be obtained

Please provide a brief overview of why this client is eligible for a U Visa

If T Visa:

Client’s country of origin

What was the nature of the trafficking the client experienced?

Is a police report available for review?

yes no can be obtained

Please provide a brief overview of why this client is eligible for a T Visa

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Referral form

Contact Michelle at:

Client information

Contact Michelle at:

Michelle Collins, LICSW