Assessment Referral Form

Contact as needed

Jenifer Wolf Williams jenifer@therapysecure.com

(918) 640-5324

Referred by (agency and contact person)

H.O.M.E. accepts referrals from nonprofit, pro bono, or low bono attorneys

Date

Agency/Office Address:

Phones (office and cell):

Fax

E-mail

I wish to refer the person below for the following service (select one specific to this case):

Mental Health Evaluation for Asylum Mental Health Evaluation for T-Visa victim of trafficking Mental Health Evaluation for Cancellation of Deportation - Hardship Mental Health Evaluation for competency to participate in proceedings Mental Health Evaluation for U – Visa victim of crime Mental Health Evaluation for VAWA Mental Health Evaluation for other

If other, specify

Date of hearing, if relevant

Last date attorney can accept final report:

Person Being Referred

Full legal name

Preferred Name

Client contact information (non-detained)

Phone, WhatsApp, email, or other. Please include all options.

Detained client - Name and location of facility

Client location by state or country

This is required even for telehealth due to licensing restrictions

Date of Birth

Date of Entry into U.S.

Gender

Sexual Orientation

Marital Status

Country of Origin

Ethnicity

Religion

English Speaker

Yes No Some

Primary Language(s)

Current Legal Status

Employment Status

Housing Status

Highest level of education

Ability to cover cost of assessment Our mission is to ensure everyone who needs an assessment can have one, regardless of ability to pay. When the client, referring agency, or sponsor is able to cover the stipend, this helps ensure donations remain for those who most need them. If the client (or sponsor) cannot cover the stipend, H.O.M.E. will gladly cover it for them.

Neither client nor sponsor is able to cover assessment cost. Referring agency, client, or supporter can cover the $400 stipend.

Brief description of the background events and basis for claim (attach additional page if needed, and declaration if available)

Files

Add file

Please upload a file

Your information will be encrypted.