Forensic Evaluation Request Form

Physicians for Human Rights





Forensic Evaluation Request Form

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
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
*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 twelve 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. 

Contact Information