H.O.M.E. Mental Health Assessment Request Form

Referring Agency and Contact Person

H.O.M.E. accepts requests from nonprofit or pro bono attorneys. Please contact us for more information if you are a private attorney.

Date

Agency/Office Address:

Phones (office and cell):

E-mail

Date of hearing, if relevant

Last date attorney can accept final report:

Do you anticipate the need for oral testimony?

Yes No Maybe

If yes, please note date and any details.

Person Being Referred

Full legal name

Preferred Name

Please list the legal petition type or types, including relevant details. Include all petition types under consideration so the evaluator can prepare appropriate interview questions.

H.O.M.E. clinicians are experienced in evaluations relevant to asylum, humanitarian parole, detention release requests, CAT, VAWA, U-Visa, T-Visa, competency, combinations of the above, and unique requests.

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.

City and 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 U.S. Entry (if applicable)

What does the clinician need to know about your client's gender, gender identity, sexual orientation, or marital/relationship status?

Country of Origin

Ethnicity

Religion

English Speaker

Yes No Some

Primary Language(s)

Please list all areas of concern you would like the evaluator to address during the clinical interview. These might include trauma events, observed mental health needs, etc. The clinician will prepare relevant interview questions, so it helps to be specific. A bullet point list is fine if that's easier, or simply refer to your attachments (see below).

Describe in detail the purpose of the mental health assessment, the psycholegal question you need us to answer, and specific needs the clinician should consider prior to the interview.

Please attach relevant documents you would like the clinician to review, including previous health and legal records. A declaration, even in draft form or the client's own language, can be helpful as the evaluator prepares. Attaching the documents here allows for HIPAA compliant encrypted transfer.

Add file

Please upload a file

Ability to cover cost of assessment Our mission is to ensure that everyone who needs an assessment can have one, regardless of ability to pay. We do not charge clients, but we ask referring agencies to assist with assessment costs at the level you are able. This helps H.O.M.E. sustain our ability to offer high quality evaluations for those with no resources. The cost of a full assessment ranges from $1000 to $1500, depending on complexity. But with the help of our generous donors, H.O.M.E. can reduce or waive this fee for our legal partners as needed. As a young non-profit, we appreciate your careful consideration and would be happy to answer any questions you may have.

Referring agency will cover the full cost of this assessment. Referring agency will partially offset the cost of this evaluation to H.O.M.E.

Please note the amount below.

The assessment cost will be covered by a third party.

Please note the funding source below.

Referring agency requests that H.O.M.E. cover the assessment costs in full.

Through the generosity of our donors, H.O.M.E. is able to provide a limited number of assessments without cost to high-need referring agencies.

Additional information or questions regarding cost

The asterisk (*) notes a required field.

Note about mandated reporting: Mental health professionals are mandated by most states and by licensing boards to report potential child abuse, elder abuse, or violent harm to others. Please contact us in advance if you would like to discuss this.

Your information will be encrypted.