Last updated: September 2019
SAMPLE CLIENT INTAKE FORM
Date:
Referred by:
Name:
Tel:(cell)
(other):
Address:
Date of Birth:
Email:
Nationality:
Place of Birth:
Immigration History
1. When did you first enter the U.S.?
When was the last time?
2. How did you enter the last time?
❑
Visa:
❑
No papers, but at a check point:
❑
Not inspected/other:
3. List all entries to and exits from the U.S. (Give dates, and whether or not you went through
an immigration inspection upon those entries.)
Entry
Exit
Inspected by
immigration
authorities?
If yes, what status (visa) did
you have on entry?
When did
authorized stay
expire?
(Make a copy of any visas and I-94s)
4. What problems have brought you here to this office? What do you hope that the
advocate can do about those problems?
Last updated: September 2019
5. Have you ever been ordered removed or deported from the U.S.?
Yes/No
6. Have you ever been in immigration court?
Yes/No
7. Have you ever been stopped by immigration officials?
Yes/No
If yes to any of the above, please describe
8. Have you ever applied for any immigration benefit? (Examples: Permanent residency,
asylum, amnesty, TPS, cancellation, suspension, Family Unity, DACA, visa petition, U visa,
T visa, SIJS, or any other immigration benefit). If so, please tell us when and what types of
paperwork:________________________________________________________________
What was the result?
9. Has any paperwork been filed on your behalf? (Visa petition by family?)
Yes/No
Family
10. Were your parent(s) or your grandparents U.S. citizens?
Yes/No
11. Are you married?
Yes/No
When and where?
Name of spouse, status, date married:
Name of previous spouse, status, and date marriage ended:
Last updated: September 2019
12. Do you have children?
Yes/No
If so, provide the following information:
Children
Date and Place of Birth
Immigration status
In U.S. now?
13. Do you have any other family members in the U.S.?
Yes/No
Name
Relation
Immigration status
In U.S. now?
14. Employment in U.S. -- Dates and types of employment, name & address of employer:
Name of Employer
Address of
Employer
Type of
Employment
Period of
Employment
Work
authorized?
15. Have you ever had trouble with the police or been arrested in the U.S.? If so when and for
what? What sentence did you receive?
_________________________________________________________________________
_________________________________________________________________________
16. Do you have any reason to fear going back to your country? Who do you fear and why?
17. Have you ever been a victim of domestic abuse by a spouse, parent or child?
Yes/No
Last updated: September 2019
18. Have you ever been threatened or harmed by a spouse, parent or child?
Yes/No
If so, did your spouse, parent or child have U.S. citizenship status or lawful
permanent residency?
Yes/No
19. Have you ever been the victim of a crime? If so, what crime?
Yes/No
If so, did you report it to the police or help with the criminal investigation or
prosecution?
Yes/No
20. Did anyone recruit you in your home country to work in the United States?
Yes/No
Did you feel forced to work or tricked into working?
Yes/No
Were you required to work without pay? (or less pay than allowed or
expected)?
Yes/No
21. Have you been abandoned, abused, or neglected by a parent? Are you
currently under the jurisdiction of a juvenile court (dependency,
delinquency or probate guardianship)?
Yes/No
Last updated: September 2019
SCREENING REMINDERS FOR THE ADVOCATE
If Undocumented:
• If parent a USC, screen for possible derivative or acquired citizenship.
• If LPR or USC parent, spouse, child, sibling, screen for possible adjustment or consular
process options.
• If harmed in home country, screen for asylum and related relief.
• If harmed in the U.S., screen for VAWA and U visa.
• If a victim of a crime, screen for VAWA, U visa, and T visa.
• If family member is in the military, screen for parole-in-place and naturalization for
military.
• If under 21, screen for possible SIJS.
• If brought to work in U.S. or forced into commercial sex act, screen for T visa.
• If TPS country, check list here: www.uscis.gov/humanitarian/temporary-protected-
status#Countries%20Currently%20Designated%20for%20TPS, screen for possible TPS or
late registration.
• If been here at least 10 years and has LPR or USC spouse, child, or parent, screen for
cancellation of removal for non- LPRs (and suspension if only conviction before April 1,
1997).
• If from El Salvador and entered the U.S. by Sept. 19, 1990 or Guatemala and entered by
Oct. 1, 1990, screen for NACARA. Screen children if parents entered by the above dates.
For LPRs:
• Screen for naturalization.
• If parent is a USC or can become a USC by the time client turns 18, screen for derivation
• If parent or grandparent a USC, screen for acquisition.
• If potential deportation:
o Cancellation of removal; and prior 212(c)
o If fear of harm in home country, screen for asylum, CAT, withholding
o If any family members in status, screen for possible re-adjustment as defense
Last updated: September 2019
COMMON FORMS OF RELIEF
U.S. Citizenship: An LPR can apply for U.S. citizenship after five years LPR status, or three years
of marriage to a USC while an LPR; must establish good moral character and should not be
deportable. But some current and former military personnel can naturalize without being LPRs.
Acquisition or Derivation of U.S. Citizenship: If the answer to any question is yes, client could
be a USC or national.
• Was the client born in the United States or its territories? Or,
• At time of his or her birth abroad, did client have a USC parent or grandparent? Or,
• Before age of 18, in either order: did client become an LPR, and did one of client’s
parents naturalize to U.S. citizenship? Or, was the client adopted by a USC before the
age of 16 and became an LPR before age 18?
LPR Cancellation: Client must be an LPR who (a) does not have an aggravated felony conviction;
(b) has been an LPR for at least five years; and (c) has lived in the U.S. for at least seven years
since being admitted in any status (e.g. as a tourist, LPR, border crossing card).
Former 212(c): An LPR whose convictions pre-date April 24, 1996 might be eligible for the
former 8 USC § 1182(c), INA § 212(c), even if the conviction(s) are aggravated felonies. Screen
for this relief if client is an LPR who is deportable based on one or more convictions for an
aggravated felony, or other deportable offense, that occurred before April 24, 1996. Section
212(c) might be available for a conviction occurring between April 24, 1996 and April 1, 1997.
Immigrating Through Family: Client might apply for a green card if has: (a) USC spouse; USC
child at least age 21; or USC parent if client is unmarried and under age 21 (“immediate
relative”); or (b) LPR spouse; LPR parent if client is unmarried; USC parent if client is at least age
21 and/or married; or USC sibling (“preference”). To immigrate through family the person must
be “admissible.” That means either she must not come within any of the grounds of
inadmissibility at INA § 212(a), or if she comes within one or more inadmissibility grounds, she
must qualify for and be granted a waiver of the ground(s). One can consular process outside the
U.S. or “adjust status” if within the U.S. and meets the requirements at INA §245. Adjustment
can be a defense for LPRs facing deportation, as well as for those who are undocumented and
are seeking LPR status.
DACA-Deferred Action for Childhood Arrivals: Client entered U.S. before turning 16 and before
6/15/2007, and is in or could enroll in certain educational programs or military. At the time of
Last updated: September 2019
this manual’s writing, DACA initial applications are no longer accepted, but DACA recipients can
continue to renew DACA. As the DACA program is in flux, check www.ilrc.org/DACA for updates.
Cancellation of Removal for Nonpermanent Residents: To be eligible for this defense in
removal proceedings, client must have lived in U.S. at least ten years and have a USC or LPR
parent, spouse or child, and not have a conviction for a deportable or inadmissible crime. The
client must show that the family member(s) will suffer exceptional and extremely unusual
hardship. The client must also be able to show good moral character for the ten years prior to
decision and warrant cancellation in discretion.
Suspension of Deportation: This relief might permit an undocumented person with old
convictions—even old drug convictions—to become a lawful permanent resident. This is a
defense under pre-1997 deportation proceedings that can be applied for in removal proceedings
arising in the Ninth Circuit Court of Appeals; other circuit courts of appeals may not have
considered the issue. The Ninth Circuit indicated that a noncitizen still may apply for suspension
of deportation today in removal proceedings, if he was convicted of a deportable offense before
April 1, 1997.
VAWA Relief: Your client, or certain family member/s, have been abused (including emotional
abuse) by a USC or LPR spouse, USC or LPR parent, or adult USC child. (If abuser is not a
USC/LPR, consider U Visa, below.)
Special Immigrant Juvenile Status: This relief is for juveniles only, and the petition must be filed
by age 21. Client must obtain a state court order (from delinquency, dependency, probate,
family court, etc. proceedings) that they can’t be returned to at least one parent due to abuse,
neglect, or abandonment.
U Visa: Client must have been a victim of a serious crime, such as DV, assault, false
imprisonment, extortion, obstruction of justice, or sexual abuse, and be or have been willing to
cooperate in investigation or prosecution of the crime.
T Visa: Client must have been victim of (a) sex trafficking of persons (if under age 18, could have
been consensual), or (b) labor trafficking, including being made to work by force, fraud, etc.
Asylum, Withholding of Removal and Convention Against Torture: If client fears harm that
amounts to persecution or even torture if returned to the home country, consider all above
forms of humanitarian protection. Asylum is preferable, because after one year the person can
apply for lawful permanent residence. An asylum applicant (a) must submit the application
within one year of entering the U.S., absent extraordinary or changed circumstances, (b) faces
stricter bars based upon criminal convictions, (c) can be denied asylum as a matter of discretion,
Last updated: September 2019
and (d) only needs to prove a “well-founded fear” of persecution (interpreted as a 10%
likelihood). There are various bars to asylum and withholding.
TPS: Noncitizens from certain countries that have experienced a devastating natural disaster,
civil war or other unstable circumstances may be able to obtain Temporary Protected Status
(TPS). See https://www.uscis.gov/humanitarian/temporary-protected-status for list of countries
and requirements. There a certain bars, including any two misdemeanors or one felony.
NACARA: Your client might be eligible if he/she (a) is from the former Soviet bloc, El Salvador,
Guatemala, or Haiti; and (b) applied for asylum or similar relief in the 1990’s or is a dependent
of such a person. Certain nationals from El Salvador, Guatemala, or former Soviet bloc countries
who applied for asylum or similar relief in the early 1990’s are eligible to apply for lawful
permanent resident status (a green card) under the 1997 Nicaraguan Adjustment and Central
American Relief Act (NACARA). See 8 CFR §240.60-65. They can apply for a special form of
suspension or cancellation of removal now, under the more lenient suspension of deportation
standards that were in effect before April 1, 1997. Persons who became deportable or
inadmissible for a criminal offense more than ten years before applying for NACARA can apply
under the lenient rules governing the former “ten-year” suspension, except that an aggravated
felony conviction is an absolute bar to NACARA. Family members of these persons also may be
eligible to apply.
