Forensic Evaluation Request Form

Physicians for Human Rights





Forensic Evaluation Request Form

Due to an increased number of requests since implementation of the zero-tolerance policy, PHR is unable to accept requests from the following geographic areas until February 1, 2019:

  • Bay Area
  • Illinois
  • Maryland
  • New Jersey
  • New York 
  • Virginia
  • Washington
  • Washington, D.C.
Please feel free to call (646) 564-3760 with any questions or concerns.
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
First Name Last Name Street City State Zip Telephone Fax Email If you are a student attorney, name and email of supervising attorney:
Supervising Attorney Section
CLIENT INFORMATION
Edit this text First Name Middle Name Last Name Gender Age Client's Country of Origin Client's Alien Registration Number Current City Current State Does the Client Speak English? If not, What is the Primary Language Spoken? Detention Center For clients outside major metropolitan areas, what nearby cities can they travel to?
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 his or her express written permission.
We will try to find a physician who can communicate with your client, but you must be prepared to provide a qualified, non-family member interpreter.
TYPE OF APPLICATION
Type of Application If applying for ASYLUM, Please check all that apply in regards to the basis for application: Reason for Asylum Evaluator Gender Preference Hearing Type Hearing Date Request Testimony Telephonic Testimony Allowed Med Student Shadow Seeking Evaluation Elsewhere
*please note, requesting a specific gender may lead to some delays in placement
We cannot guarantee that the evaluator can testify
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
PLEASE NOTIFY PHR IMMEDIATELY IF YOU SECURE AN EVALUATION ELSEWHERE AND WOULD LIKE TO WITHDRAW YOUR REQUEST.
REQUEST EVALUATION(S)
Please note that we require a minimum of eight weeks to complete an evaluation and an affidavit. Generally, the more time clinicians have, the more likely they are to volunteer to evaluate your client.

DETAILS OF THE CASE
Please briefly describe in 4-5 sentences the persecution your client suffered and what you’re hoping to document through a forensic evaluation. Attorneys must include the physical scars and/or psychological concerns that they are seeking to document; PHR cannot use volunteer resources to evaluate clients with no visible scars, injuries, disabilities, or psychological concerns.
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.