Assessment Referral Form

Referring Agency and Contact Person

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

Date

Agency/Office Address:

Phones (office and cell):

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 U-Visa Mental Health Evaluation for T-Visa Mental Health Evaluation for VAWA Hardship Evaluation for Family Member Urgent Needs Assessment for Humanitarian Parole Urgent Needs Assessment for MPP Exemption Other

If other, specify

Date of hearing, if relevant

Last date attorney can accept final report:

Person Being Referred

Full legal name

Preferred Name

A - Number (NA if not available)

Detained Client - Facility and Location

Client contact information (non-detained)

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

US State (or non-US nation) where client will be at time of interview

This is required even for telehealth due to licensing restrictions

Date of Birth

Date of Entry into U.S. (if applicable)

Gender

Sexual Orientation

Marital Status

Country of Origin

Ethnicity

Religion

English Speaker

Yes No Some

Primary Language(s)

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 direct costs to H.O.M.E., this helps ensure donations remain for those who most need them. If the client, sponsor, or referring agency cannot cover the cost of assessment, H.O.M.E. will do our best to cover it for them.

Neither client, sponsor, nor referring agency is able to cover assessment cost. Referring agency, client, or supporter can cover the $500 costs for a full assessment ($250 for a limited assessment).

Reason for referral

Describe in detail the purpose of the mental health assessment, what needs you have observed in the client, and how those needs intersect with the immigration process.

Please attach relevant documents you would like us to consider for the assessment.

Add file

Please upload a file

Mandated reporting

Please note that mental health professionals are mandated by most states and by licensing boards to report potential child abuse, elder abuse, or violent harm to others.

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