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 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.

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 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. We offer clinicians a modest stipend to support their frequent engagement and advancing expertise. When the referring agency covers these stipends, this helps H.O.M.E. sustain our ability to offer high quality evaluations. As a young non-profit, our funding is limited, and we appreciate your willingness to help at the level you can.

Referring agency or supporter will cover the direct costs of this request ($500 for a full assessment or $250 for a limited review). Referring agency cannot fully cover the cost of this assessment but will contribute a partial amount. Referring agency requests that H.O.M.E. cover the assessment costs in full.

Reason for referral

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. Previous health and legal records can help us prepare good interview questions.

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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.

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