Asylum Network Application to Join

Asylum Network Application to Join

Contact Information

Salutation

First Name

Last Name

Phone

Preferred Address

HomeWork

Home Address

Street

City

State

Postal Code

Organization/Hospital Affiliation

Organization or Hospital Affiliation

Street

City

State

Postal Code

Health Professional Information

Health Professional Type

Specialty

Licensing Status

License

PHR only accepts residents as members who are part of a PHR asylum clinic. Which clinic are you a member of?

When do you expect to have your license to practice?

In which state(s) are you licensed to practice?

Please select any languages that you have a basic level of understanding

Please select any languages in which you are fluent.

Volunteer Interest

What types of evaluations are you able to perform?

Do you have a preference of client gender?

No PreferenceFemaleMale

Where can you see clients?

In my officeIn a detention centerRemote/virtual

In which state(s) are you licensed to practice in?

To select multiple states, hold down the Ctrl key as you click on each state.

How many evaluations are you interested in completing per year?

In which issues do you have clinical interest?

Are you interested in working on domestic investigations or medical record review for immigration detainees or others in US custody?

Yes

Please describe any relevant/related training or experience with forensic evaluations

“Please provide a copy of your medical license in every state where you are licensed.”

You can upload multiple files by selecting "Add another response" in the bottom right corner of this question.

Please provide a copy of your CV.

If you have completed an asylum forensic evaluation training, please select the location.

Please provide a copy of your completion certificate of an asylum forensic evaluation training.

Advocacy Interest

Are you interested in volunteering with any other programs run by PHR?

Yes

Please select any programs of interest

Do you have any experience with international volunteering, work or investigations?

Yes

Do you have interest in traveling to conflict zones?

Yes

How long would you be willing to travel?

months

Please list any geographic locations to which you would be interested in traveling.

Please describe any time you have lived or worked under difficult conditions.

Contact Information