Patient Name

DOB

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Birth Information

Birth Date

City of Birth

Country of Birth

Sex

Ethnicity

Religion

Language(s)

Attorney Information

Marital Status

Date of Marriage

Spouse’s Name

Marital Information

Name

Address

Office Phone

Fax

Family Members Living With You

Name

Relation

Place & Date of Birth

Occupation / Education

Preferred Means of Contact

May we leave voice messages on the mobile number provided?

yes No

May we send e‑mails (non‑clinical matters)?

yes No

May we send text messages (non‑clinical matters)?

yes No

Type of Immigration Case (check one)

Extreme Asylum  Abuse (Domestic Violence, Crime Victim – U or T Visa, abused spouse/child/parent)

Brief Description of Your Immigration Case:

Education History (check the highest level attended)

Learning / Behavioral Difficulties while in school (specify):

Employment History (list all jobs, starting with current)

Employer

Position

Responsibilities

Dates of Employment

Immigration History

Are you a U.S. Citizen? (If Yes, skip to next section)

yes No

Date you entered the U.S.

How did you enter the U.S.

With whom did you enter

Please share your reasons for coming to the U.S.

Legal History

Have you ever been arrested or detained?

Yes No

If Yes, describe:

Have you ever been the victim of a crime?

Yes No

If Yes, describe:

Name

Date

Address

Home#

Mobile #

Type of information to be released: Psychological and Behavioral Information Purpose of release: Psychological Evaluation and Current Functioning Assessment between attorney and assigned therapist at Integral Mental Health Counseling, PLLC

To / From (Attorney)

I authorize the periodic disclosure and use of the information specified above to the person identified, as needed to coordinate any treatments or testing. I understand I have the right to revoke this consent at any time. My consent to release information to the person/service named above will expire when I am no longer receiving services or one year from the date below, whichever occurs first

Name

Date

Consent(Required)

by clicking here, I understand and I submit my electronic signature

Immigration Form