Asylum Network Application to Join

Asylum Network Application to Join

Contact Information

First Name 

Last Name

Phone

Email

Preferred Address

HomeWork

Home Address

Street

City

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Postal Code

Organization/Hospital Affiliation

Organization or Hospital Affiliation

Street

City

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Postal Code

Health Professional Information

Health Professional Type

Please select... Administrator Forensics Non-MD Nurse Other Scientist Pharmacist Physician Psychiatrist Psychologist Public Health Social Work Other Health Professional

Specialty

Please select... Acupuncture Adult Psychology Allergy Andrology Anesthesiology Bioethics Cardiology Child Psychiatry Clinical Social Worker Community Health Critical Care Dentistry Dermatology Emergency Medicine Endocrinology Environmental Medicine Epidemiology Family Medicine Family Practice Forensic Pathology Forensic Psychiatry Forensic Psychology Gastroenterology Geriatric Psychology Geriatrics Hematology Human Brain Mapping Immunology Infectious Disease Internal Medicine Nephrology Neurology Neuropsychology Neurosurgery OB/GYN Occupational Health Oncology Ophthalmologist Orthopaedics Other Otolaryngology Pathology Pediatrics Plastic Surgery Podiatry Preventative Medicine Primary Care Psychiatry Psychology Psychotherapy Pulmonary Radiology Social Medicine Surgery Toxicology Trauma Medicine Tropical Medicine Urology Vascular Surgery

Licensing Status

Please select... Resident Board Licensed Licensed Clinical Social Worker Student

When do you expect to have your license to practice?

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

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

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

Please select... Amharic Arabic Armenian ASL (American Sign Language) Bambara Bayangui Bengali Bosnian Burmese Cantonese Chichewa Chinese Croatian Dari Dioula Dutch English Ethiopian Ewe Farsi French French Creole Fulani Georgian German Greek Guerze Gujarati Haitian Creole Hebrew Hindi Hungarian Igbo Indonesian Italian Japanese Kannada Kenyang Khmer Kiche Kinyarwanda Kirundi Kiswahili Korean Lingala Luganda Malayalam Mam Mandinka/Madingo/Malinke Marathi Mongolian Moore Nepali Nweh Other Persian Polish Portuguese Punjabi Romanian Russian Serbo-Croatian Sinhalese Somali Spanish Swahili Tagalog Tamil Telugu Thai Tibetan Tigirina/Tigrinya Toma Tonga Turkish Twi Ukranian Urdu Vietnamese Yoruba

Please select any languages in which you are fluent.

Please select... Amharic Arabic Armenian ASL (American Sign Language) Bambara Bayangui Bengali Bosnian Burmese Cantonese Chichewa Chinese Croatian Dari Dioula Dutch English Ethiopian Ewe Farsi French French Creole Fulani Georgian German Greek Guerze Gujarati Haitian Creole Hebrew Hindi Hungarian Igbo Indonesian Italian Japanese Kannada Kenyang Khmer Kiche Kinyarwanda Kirundi Kiswahili Korean Lingala Luganda Malayalam Mam Mandinka/Madingo/Malinke Marathi Mongolian Moore Nepali Nweh Other Persian Polish Portuguese Punjabi Romanian Russian Serbo-Croatian Sinhalese Somali Spanish Swahili Tagalog Tamil Telugu Thai Tibetan Tigirina/Tigrinya Toma Tonga Turkish Twi Ukranian Urdu Vietnamese Yoruba

Volunteer Interest

What types of evaluations are you able to perform?

Please select... Dental Gynecological Medical Record Review Neuropsychological Opthalmological Other Physical Psychological Psychological/Competency

Do you have a preference of client gender?

No PreferenceFemaleMale

Where can you see clients?

In my officeIn a detention center

In which states can you evaluate clients?

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

How many evaluations are you interested in completing per year?

In which issues do you have clinical interest?

Please select... Detention/Prison Health Domestic Violence Gang Violence HIV/AIDS Human Trafficking LGBT Sexual/Gender-based Violence

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

Yes

No

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

Please provide a copy of your medical license.

Please provide a copy of your CV.

Advocacy Interest

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

Yes

No

Please select any programs of interest

Please select... Advocacy Interest (High Level) Anti-Torture Asia Conflict Zone Human Rights Violations Domestic Investigations - Asylum/Immigration, Detention, Human Rights Violations Forensic Investigations International Investigations Mass Atrocities National Security Anti-Torture Persecution of Healthy Professionals/Medical Neutrality SGBV/Sexual Violence/Rape in War Women’s Health Protection

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

Yes

No

Do you have interest in traveling to conflict zones?

Yes

No

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.

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