Forensic Evaluation Request Form

Physicians for Human Rights





Forensic Evaluation Request Form

Please note that PHR cannot guarantee an evaluation for your client, but we will make every effort to locate a clinician within our network of volunteers to conduct an evaluation that aligns with your timeframe.  

 

Before we process your request and engage in outreach efforts to locate a clinician to support your case, please ensure that you are able to provide the evaluator with all of the documentation and related materials necessary to conducting the evaluation, including but not limited to the client’s affidavit and all relevant medical records. The evaluator needs sufficient time to look over this material prior to the evaluation. Please note that we will not connect you with a clinician if you do not have the relevant material at the time of a placement. 

PLEASE ONLY SUBMIT AS A DIRECT REFERRAL IF A MEDICAL SCHOOL ASYLUM CLINIC HAS ALREADY AGREED TO EVALUATE YOUR CLIENT.
Clinic Information
ATTORNEY CONTACT INFORMATION
Supervising Attorney Section
CLIENT INFORMATION
Attorneys MUST submit a separate request for each client, children WILL NOT be included automatically. If you would like to submit multiple requests for different evaluation types for one client, please only fill out ONE form indicating multiple evaluation requests. 
By consenting to an evaluation, your client grants PHR permission to use information gained from the evaluation in its advocacy efforts to fight persecution around the world. All information will be de-identified and data aggregated for inclusion in PHR reports and materials. PHR will never disclose your client’s name, A-number, or any other identifying information without their express written permission. Check this box to confirm that your client has consented.



TYPE OF APPLICATION
(mm/dd/yyyy)
PHR does not request or require volunteers to provide oral testimony. If we are able to connect you with a volunteer to conduct an evaluation and you would like them to then provide oral testimony, you must initiate the conversation and understand that they are not required to provide it. If they agree to do so, you must be able to support them through all preparation and other logistics.  
Please notify PHR immediately if you secure an evaluation elsewhere.
REQUEST EVALUATION(S)
Again, please note that we are not able to guarantee a placement. However, we kindly require a minimum of twelve weeks to attempt to place an evaluation request. Generally, the more time clinicians have, the more likely they are to volunteer to evaluate your client.
*please note, requesting a specific gender may lead to some delays in placement
Many of our health professionals work at asylum clinics and teaching hospitals, providing experience to future evaluators. Please note, PHR will not conduct outreach to these asylum clinics if this box is left unchecked; this will decrease the number of potential evaluators and may lead to some delays in placement. 
DETAILS OF THE CASE
UN CONVENTION AGAINST TORTURE
Please note this is for statistical purposes only; your response will have no effect whatsoever on the case placement of your client.
*UN Convention Against Torture definition: torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions. 

Contact Information