N648 Referral Form

N648 Referral Form

The N648 is a form that grants someone a medical exemption from having to take the U.S. Citizenship exam. This means that there is a medical diagnosis that explains why a person cannot learn U.S. history and government or to read, write, or speak English. Lack of literacy in a person’s native language or normal age-related memory loss do not qualify for an N648 as these are not medical diagnoses. It is very uncommon and highly unlikely for someone under the age of 55 to be granted an N648.

Participation in the assessment does not guarantee the n648 form will be completed. This is based on whether an official diagnosis is determined.

What to bring for an N648 assessment:

List of medications

Residency card /green card

Medical records from PCP office or any relevant specialists (ex: neurology):
-list of medical diagnoses
-relevant medical records from your country of origin
-mental health records if you have seen a mental health specialist (therapist, counselor, or psychiatrist)

A knowledgeable informant (someone who lives with you or a family member who participates in your caregiving or assists you with activities of daily living). This person can also serve as the interpreter.

Reading glasses or any aids you need to participate in reading or seeing pictures needed for the assessment

The person completing this form is:

The person completing this form is: Client Relative/ Family Member Attorney/ Legal Representative Other Other
Name of referral person: Name of referral person: First Last
Person filling out this form.
Phone: Phone: - ### - ### ####
Email:
Date report is needed by: Date report is needed by: / MM / DD YYYY
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/ I don't know 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 Unknown
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 intake forms electronically?

Is the client comfortable completing 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
Does the client consent to the use of an interpreter?

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

Confirm Email Address:
Date of Birth: Date of Birth: / MM / DD YYYY
Age:
Birthplace:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Children and ages:
Language of choice:
Level of Education:
Are you applying for an N648 based on the following (click all that apply)

Are you applying for an N648 based on the following (click all that apply) Memory Problems Medical Diagnoses (e.g. diabetes, hypertension, stroke, ect...) Learning Disability Intellectual Disability PTSD Major Depression Other Mental Health Condition Other Mental Health Condition
List any other known major health issues:
List any prescription medications of the client:
This client may qualify for funding. Please state the estimated monthly income & number of people living in the household:
Family Member/ Informant

This could be a family member or peer support specialist who understands the client’s functioning and changes. This person can also serve as an interpreter.
Name: Name: First Last
Phone: Phone: - ### - ### ####
Email:

Confirm Email Address:
Can you serve as interpreter?
What's your relationship to the client?
Who referred you to us?
Spam Protection. Please answer this simple question:
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