Forensic Evaluation Request Form
Forensic Evaluation Request Form
Are you submitting a request to PHR or to a medical school asylum clinic?
PHR Request
Clinic Direct Referral
PLEASE ONLY SUBMIT AS A DIRECT REFERRAL IF A MEDICAL SCHOOL ASYLUM CLINIC HAS ALREADY AGREED TO EVALUATE YOUR CLIENT.
Clinic Information
Clinic Name
Please select...
Baylor Asylum Clinic
Brown Human Rights Asylum Clinic (BHRAC)
Buffalo Human Rights Initiative
Columbia HRI Asylum Clinic
Georgetown Med PHR
Georgia Human Rights Clinic
Harvard Student Human Rights Collaborative (HSHRC)
Los Angeles Human Rights Initiative (UCLA Asylum Clinic)
New York Medical College Asylum Clinic
NYU Postdoctoral Clinic - Human Rights
Olive View-UCLA Human Rights Clinic
Philadelphia Human Rights Clinic (PHRC)
SUNY Downstate Asylum Clinic
University of Arizona Asylum Clinic
University of Connecticut Immigration Rights Initiative
University of Michigan Asylum Collaborative (UMAC)
USC-Keck Human Rights Clinic
Weill Cornell Center for Human Rights (WCCHR)
Chicago People's Rights Collaborative
ATTORNEY CONTACT INFORMATION
Agency/Firm
First Name
Last Name
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
Zip
Telephone
Fax
Email
If you are a student attorney, name and email of supervising attorney:
If you are a student attorney, check here and provide supervising attorney information
Supervising Attorney Section
First Name
Last Name
Email Address
CLIENT INFORMATION
Attorneys MUST submit a separate request for each client, children WILL NOT be included automatically
Edit this text
Has your client consented to be evaluated by a PHR Asylum Network member?
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.
First Name
Middle Name
Last Name
Gender
Male
Female
Other (please specify in details of case)
Age
Client's Country of Origin
Please select...
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong S.A.R., China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Client's Alien Registration Number
Current City
Current State
Please select...
Alabama
Alaska
Arizona
Arkansas
Armed Forces Asia
Armed Forces Europe
Armed Forces Pacific
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
What type of evaluation is the client comfortable with?
Please select...
In person
Virtual
Both
Does the Client Speak English?
Please select...
Yes
No
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.
If not, What is the Primary Language Spoken?
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
Detention Center
Client Detained?
For clients outside major metropolitan areas, what nearby cities can they travel to?
TYPE OF APPLICATION
Type of Application
Please select...
Asylum
Cancellation of Removal
CAT Withholding
Family Separation
Other
Special Immigrant Juvenile Status
T Visa
U Visa
Violence Against Women Act (VAWA)
Withholding of Removal
If applying for ASYLUM, Please check all that apply in regards to the basis for application:
Please select...
Race
Religion
Nationality
Membership in a Social Group
Political Opinion
Reason for Asylum
Please select...
Domestic Violence
Female Genital Cutting
Foreign Detention
Gang Violence
Kidnapping
LBGTQIA
One Child Policy
Other
Sensory Deprivation
Sexual Violence
Slavery
Trafficking
Evaluator Gender Preference
Please select...
Male
Female
No Preference
*please note, requesting a specific gender may lead to some delays in placement
Hearing Type
Please select...
Master Calendar
Individual
Interview
Merit
Final
Hearing Date
Request Testimony
Are you requesting oral testimony?
We cannot guarantee that the evaluator can testify
Telephonic Testimony Allowed
Is telephonic testimony acceptable?
Med Student Shadow
Would your client be comfortable with a medical student shadowing the evaluation?
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
Seeking Evaluation Elsewhere
Are you seeking an evaluation through any other organization?
PLEASE NOTIFY PHR IMMEDIATELY IF YOU SECURE AN EVALUATION ELSEWHERE AND WOULD LIKE TO WITHDRAW YOUR REQUEST.
REQUEST EVALUATION(S)
Target Affidavit Date
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.
Target Affidavit Date
Evaluation Type
Please select...
Gynecological
Medical Record Review
Neuropsychological
Opthalmological
Other
Physical
Psychological
Psychological/competency
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 TORTUR
E
Has your client been subjected to torture as it is defined in the United Nations 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