Sample Intake Form

SAMPLE INTAKE FORM
DATE:_________________ INTAKE BY:__________________
BIOGRAPHIC
NAME_________________________________________ A#_____________________
ADDRESS____________________________________________________________________
PHONE #__________________CELL #______________ E-MAIL ADDRESS______________
DATE OF BIRTH______________________ COUNTRY OF BIRTH_____________________
CITIZENSHIP__________________COUNTRY OF LAST RESIDENCE__________________
GENDER____________MARITAL STATUS Single Married Divorced Widowed
Current Spouse’s Name:

Date of Marriage:
Place of Marriage:
Immigration Status of
Spouse:
Place of Birth Immigration

Child(ren) Date of Birth
Status
CURRENT IMMIGRATION STATUS/HISTORY
Current Immigration Status: U.S. Citizen Lawful Permanent Resident Refugee

Asylee Nonimmigrant __________ No Lawful Status Other:_____________
Date of ALL entries into the United Port of Entry/ Place of Entry Manner or Entry
States:
(i.e, EWI, B-2, F-1, etc.)
Beginning with the most recent one
EXPIRATION OF CURRENT STAY_______________________________________________
EXPIRATION OF VISA: ________________________________________________________
EXPIRATION OF PASSPORT: ___________________________________________________
FAMILY MEMBERS
DO YOU HAVE FAMILY MEMBERS WHO ARE US CITIZENS ? YES NO

IF YES, LIST RELATIONSHIPS:
______________________________________________________________________________
______________________________________________________________________________
DO YOU HAVE FAMILY MEMBERS WHO ARE LAWFUL PERMANENT RESIDENTS ?

YES NO
______________________________________________________________________________
______________________________________________________________________________
DO YOU HAVE A SPOUSE, PARENT, SON OR DAUGHTER WHO IS OR WAS IN THE

ARMED FORCES IN THE US ? YES NO
______________________________________________________________________________
______________________________________________________________________________
PREVIOUS INTERACTIONS WITH IMMIGRATION
HAVE YOU EVER FILED ANY PETITONS/APPLICATONS OR HAS ANYONE FILED

PETITIONS/APPLICATION ON YOUR BEHALF WITH MMIGRATION ? YES NO
IF YES, EXPLAIN:
______________________________________________________________________________
HAVE YOU EVER BEEN IN DEPORTATION PROCEEDINGS? YES NO

IF YES, EXPLAIN:
______________________________________________________________________________
CALL THE EOIR AT 1-800-898-7180 IF- PERSON HAS A #. IS THE PERSON’S
A# FOUND IN THE SYSTEM? YES NO
INFORMATION PROVIDED FROM THE EOIR’S AUTOMATED SYSTEM
________________________________________________________________________
HAVE YOU EVER BEEN DETAINED BY IMMIGRATION? YES NO

IF YES, EXPLAIN:
______________________________________________________________________________
CRIMINAL HISTORY
HAVE YOU EVER BEEN ARRESTED IN THE US OR ANYWHERE ELSE IN THE

WORLD? YES NO
HAVE YOU EVER BEEN TO JAIL OR PRISON IN THE USE OR ANYWHERE ELSE IN
THE WORLD? YES NO
HAVE YOU EVER HAD YOUR FINGERPRINTS TAKEN? YES NO
HAVE THE POLICE EVER TAKEN YOUR PICTURE? YES NO
HAVE YOU EVER BEEN TO THE POLICE STATION? YES NO
HAVE YOU EVER TAKEN A RIDE IN A POLICE CAR? YES NO
IF ANSWERED YES TO ANY OF THESE QUESTIONS:
WHEN ? WHAT HAPPEN ? OUTCOME ?
______________________________________________________________________________
______________________________________________________________________________
ADDITIONAL SCREENING QUESTIONS
HAVE YOU EVER CLAIMED TO BE A U.S. CITIZEN ORALLY OR IN WRITING ?
YES NO
IF YES, DESCRIBE CIRCUMSTANCES:___________________________________________
______________________________________________________________________________
HAVE YOU EVER USED FALSE DOCUMENTS TO ENTER THE US OR GAIN AN

IMMIGRATION BENEFIT ?
YES NO
______________________________________________________________________________
DID YOU FLEE PERSECUTION IN YOUR HOME COUNTRY OR ARE YOU AFRAID OF
RETURNING TO YOUR HOME COUNTRY ? YES NO
______________________________________________________________________________
______________________________________________________________________________
HAVE YOU OR A CLOSE FAMILY MEMBER BEEN THE VICTIM OF A CRIME ?
YES NO
______________________________________________________________________________
______________________________________________________________________________
HAVE YOU BEEN HARMED (PHYSICALLY OR PSYCHOLOGICALLY) BY A USC OR

LPR SPOUSE, PARENT OR ADULT USC SON OR DAUGHTER ? YES NO
______________________________________________________________________________
ADDITIONAL INFORMATION/DESCRIPTION OF ISSUES/CONCERNS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PLAN OF ACTION:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Sample Intake Form

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SAMPLE INTAKE FORM

DATE:_________________ INTAKE BY:__________________

PHONE #__________________CELL #______________ E-MAIL ADDRESS______________

DATE OF BIRTH______________________ COUNTRY OF BIRTH_____________________

CITIZENSHIP__________________COUNTRY OF LAST RESIDENCE__________________

GENDER____________MARITAL STATUS Single Married Divorced Widowed

Current Spouse’s Name:

Place of Birth Immigration

CURRENT IMMIGRATION STATUS/HISTORY

Current Immigration Status: U.S. Citizen Lawful Permanent Resident Refugee

DO YOU HAVE FAMILY MEMBERS WHO ARE US CITIZENS ? YES NO

DO YOU HAVE FAMILY MEMBERS WHO ARE LAWFUL PERMANENT RESIDENTS ?

DO YOU HAVE A SPOUSE, PARENT, SON OR DAUGHTER WHO IS OR WAS IN THE

PREVIOUS INTERACTIONS WITH IMMIGRATION

HAVE YOU EVER FILED ANY PETITONS/APPLICATONS OR HAS ANYONE FILED

HAVE YOU EVER BEEN IN DEPORTATION PROCEEDINGS? YES NO

INFORMATION PROVIDED FROM THE EOIR’S AUTOMATED SYSTEM

HAVE YOU EVER BEEN DETAINED BY IMMIGRATION? YES NO

HAVE YOU EVER BEEN ARRESTED IN THE US OR ANYWHERE ELSE IN THE

HAVE YOU EVER HAD YOUR FINGERPRINTS TAKEN? YES NO

HAVE THE POLICE EVER TAKEN YOUR PICTURE? YES NO

HAVE YOU EVER BEEN TO THE POLICE STATION? YES NO

HAVE YOU EVER TAKEN A RIDE IN A POLICE CAR? YES NO

IF ANSWERED YES TO ANY OF THESE QUESTIONS:

WHEN ? WHAT HAPPEN ? OUTCOME ?

ADDITIONAL SCREENING QUESTIONS

HAVE YOU EVER CLAIMED TO BE A U.S. CITIZEN ORALLY OR IN WRITING ?

IF YES, DESCRIBE CIRCUMSTANCES:___________________________________________

HAVE YOU EVER USED FALSE DOCUMENTS TO ENTER THE US OR GAIN AN

IF YES, DESCRIBE CIRCUMSTANCES:___________________________________________

IF YES, DESCRIBE CIRCUMSTANCES:___________________________________________

HAVE YOU OR A CLOSE FAMILY MEMBER BEEN THE VICTIM OF A CRIME ?

IF YES, DESCRIBE CIRCUMSTANCES:___________________________________________

HAVE YOU BEEN HARMED (PHYSICALLY OR PSYCHOLOGICALLY) BY A USC OR

IF YES, DESCRIBE CIRCUMSTANCES:___________________________________________

ADDITIONAL INFORMATION/DESCRIPTION OF ISSUES/CONCERNS:

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DATE:_ INTAKE BY:__

PHONE #__CELL # E-MAIL ADDRESS

DATE OF BIRTH__ COUNTRY OF BIRTH_

CITIZENSHIPCOUNTRY OF LAST RESIDENCE