Revised Intake Form

Number: _____
Irish International Immigrant Center

Immigration Legal Services Intake Form
All information on this form is confidential. It helps us give you the best service possible. It is also used to compile information
required by those who fund our programs. Please follow the instructions and fill in as much information as you can. If you
have any questions, please ask one of the IIIC staff or volunteers.
FOR OFFICE USE
Date:
Legal
Clinic
Office
Appointment
Consult
Call
Email
Inquiry
Repeat Client
Yes No U/K
Staff/Volunteer Name:
A. INFORMATION ABOUT YOU

Last Name
First Name
Street Address
Apt #
Is it OK to send mail and/or email to you?

Preferred Telephone
Home
Cell
Yes
No
Work
What is the best way to contact you?

Phone
Email
Mail
Country of Origin
Middle Name
Gender
M F
Date of Birth
City
State
Zip Code
Is it OK to leave a message on your phone?
Yes
No
Email Address
Marital Status
Single
Married
Divorced
Engaged Separated Widowed
If Ireland, what city/county?
Preferred Language
When did you last enter the U.S.?
Do you have previous entries into the U.S.?

When?
Manner of Last Entry (Type of Visa)
A# (if any)
What is your current immigration status?
Expiration Date
Yes
No
B. INFORMATION ABOUT THE IMMIGRANT, IF A DIFFERENT PERSON THAN ABOVE

Last Name
First Name
Middle Name
Gender
M F
Date of Birth
City
State
Zip Code
Street Address
Apt #
Is it OK to send mail and/or email to him/her? Yes No
Is it OK to leave a message on his/her phone?
Preferred Telephone
Email Address
Home
Cell
Work
What is the best way to contact you?

Phone
Email
Mail
Marital Status
Country of Origin
If Ireland, what city/county?
Yes
No
Single
Married
Divorced
Engaged Separated Widowed
Preferred Language
When did s/he last enter the U.S.?
Does s/he have previous entries into the U.S.? Yes

When?
Manner of Last Entry (Type of Visa or Without Inspection)
A# (if any)
What is his/her current immigration status?
Expiration Date
No
C. YOUR QUESTIONS

Please write your questions here.
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Revised Intake Form

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Revised Intake Form

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Number: _____

Irish International Immigrant Center

A. INFORMATION ABOUT YOU

Is it OK to send mail and/or email to you?

What is the best way to contact you?

Is it OK to leave a message on your phone?

If Ireland, what city/county?

When did you last enter the U.S.?

Do you have previous entries into the U.S.?

Manner of Last Entry (Type of Visa)

What is your current immigration status?

B. INFORMATION ABOUT THE IMMIGRANT, IF A DIFFERENT PERSON THAN ABOVE

Is it OK to send mail and/or email to him/her? Yes No

Is it OK to leave a message on his/her phone?

What is the best way to contact you?

If Ireland, what city/county?

When did s/he last enter the U.S.?

Does s/he have previous entries into the U.S.? Yes

Manner of Last Entry (Type of Visa or Without Inspection)

What is his/her current immigration status?

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