Extreme Hardship Referral Form

Attorney Name (accredited legal representative): Attorney Name (accredited legal representative): First Last
Attorney Phone: Attorney Phone: - ### - ### ####
Attorney Email:

Confirm Email Address:
Legal Assistant/ Paralegal Name: Legal Assistant/ Paralegal Name: First Last
Legal Assistant/ Paralegal Email Address:

Confirm Email Address
Date report is needed by: Date report is needed by: / MM / DD YYYY

Please note that evaluations completed within one year of the expected court date are considered current. Evaluations completed outside of that may require an updated evaluation.
Is this date flexible?

Is this date flexible? Yes No Other Other
Are you affiliated with any of these organizations?

Are you affiliated with any of these organizations? SOAR IRCO LCS Catholic Charities ICS None Other Other
How much can your organization contribute to the cost of this evaluation?
Is this an Equity Corps referral?

Is this an Equity Corps referral? Yes No
If this is an ECO case, what is the client ECO ID number?
Do you prefer that the evaluation be done via telehealth or in person?

Do you prefer that the evaluation be done via telehealth or in person? Telehealth In person No preference Other Other
Is the client comfortable completing the intake forms electronically?

Is the client comfortable completing the intake forms electronically? Yes No
Is the client comfortable setting up a video appointment electronically?

Is the client comfortable setting up a video appointment electronically? Yes No
Will the client require assistance with the above?

Will the client require assistance with the above? Yes No
Can you provide an office space for the evaluation if needed?

Can you provide an office space for the evaluation if needed? Yes No
Does the client consent to the use of an interpreter?

Does the client consent to the use of an interpreter? Yes No
Qualifying Relative Information
Name: Name: First Last
Phone: Phone: - ### - ### ####
Email:

Confirm Email Address:
Date of Birth: Date of Birth: / MM / DD YYYY
Age:
Birthplace:
Current Address: Current Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Relationship Status:
Relationship to non US Citizen
Number of years in current relationship:
Occupation:
Employer:
Education:
Language of choice:
Number of Children:
Age of Children:
List any known major health issues for qualifying relative:
What is the primary presenting harship of the qualifying relative?
Relevant History

Please note any known traumas, mental health, medical, legal, or other relevant history.
Define the questions you want addressed in the psychological evaluation:
Non US Citizen Information
Name: Name: First Last
Phone: Phone: - ### - ### ####
Email:
Date of Birth: Date of Birth: / MM / DD YYYY
Age:
Birthplace:
Current Address: Current Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
If different from qualifying relative.
Relationship Status:
Occupation:
Employer:
Education:
Language of choice:
Number of Children:
Age of Children:
List any known major health issues for non-US citizen:
Relevant History

Please note any known trauma, mental health, medical, legal, or other relevant history.
This client may qualify for funding. Please state the estimated monthly income & number of people living in the household:
Will testimony in court be needed?

Will testimony in court be needed? Yes No Other Other
Spam Protection. Please answer this simple question:
4, 5, 6, 7 : the 3rd number is?

Extreme Hardship Referral Form

Extreme Hardship Referral Form

Qualifying Relative Information

Non US Citizen Information