Asylum Network Application to Join
Asylum Network Application to Join
Contact Information
First Name
Last Name
Phone
Email
Preferred Address
Home
Work
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...
Nurse
Physician
Psychiatrist
Psychologist
Social Work
Other Health Professional
Specialty
Please select...
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
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 Preference
Female
Male
Where can you see clients?
In my office
In 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.
Contact Information