New Patients

Immigration Form

Immigration Evaluation – Specific Information

Specific Information for Immigration Assessment
Name:(Required)
Address
Birth Information
MM slash DD slash YYYY
Attorney Information
Marital Information
Family Members Living With You
Name
Relationship
Place & Date of Birth
Occupation / Education
Preferred Means of Contact
May we leave voice messages on the mobile number provided?
May we send e‑mails (non‑clinical matters)?
May we send text messages (non‑clinical matters)?
Type of Immigration Case (check one)
Education History (check the highest level attended)
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)
Legal History
Have you ever been arrested or detained?
Have you ever been the victim of a crime?
Name(Required)
MM slash DD slash YYYY
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
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
Consent(Required)
MM slash DD slash YYYY