General Intake Form

Referred by: 

Name: 

Work Phone:  Home Phone 

Email Address: 

Address: 

Date of Birth: 

Nationality: 

Place of Birth: 

Country Lived in Before U.S.: 

How long lived in the U.S.: 

Were your parent(s) or your grandparent(s) U.S. citizens?YesNo

Have you applied for U.S. citizenship? If so, when and where?

Close relatives in the U.S.:

Legal Status:

If with visa, what type and when does/did authorized stay expire?(Make a copy of the visa and I-94)

List all entries and exits of the U.S. (Give dates, and whether went through INS inspection on entries):

Have you applied for an extension of your visa? YesNo

If entered on a temporary visa, have you violated its conditions? If so, when?

Are you married?  Yes No

When and where? 

Name of spouse, status, date married:

Name of previous spouse, status, date marriage ended:

Children:

Date and Place of Birth:

Employment in US: dates and type of employment, name & address of employer

Skills:

Was work unauthorized? Yes No

Have you ever applied for permanent residency, asylum, amnesty, TPS, cancellation, suspension, Family Unity or any other immigration benefit? When and how:

Have you ever had trouble with the police or been arrested in the US? If so when and for what? What sentence did you receive?

Have you ever had any contact with the INS or Border Patrol? If so, when and what happened?

Have you ever gone before an immigration judge? If so, when and what happened?

Have you ever been ordered deported, excluded, or been given voluntary departure? If so, did you leave and in a timely manner?

Do you have any reason to fear going back to your country? Who do you fear and why?