Human Rights Clinic (HRC) Referral Form

The Human Rights Clinic has partnered with Partnerships for Trauma Recovery (PTR) in regard to the provision of forensic medical evaluation , psychological care, case management and clinical coordination.  Data is shared between the two organizations in order to facilitate case management, clinical care, and record-keeping. If you have any questions regarding this partnership please reach out directly at humanrightsclinic@alamedahealthsystem.org.

Please note that this form should reach the HRC at least 8 weeks before the affidavit is required. Due to the heavy demand for forensic evaluations, HRC cannot guarantee securing an evaluation for every case. The probability that your client will be seen increases with advance notice. We can occasionally accommodate more urgent requests on a case-by-case basis.
Information of Individual Making a Referral
Please provide your relationship to the prospective client as well as your contact information

Please ensure the client's consent to provide demographic information prior to completing this referral

Referral Source Contact Information





Client Scheduling Information





If client's date of birth is unknown, please estimate a DOB by entering 1/1/YYYY with a year that would result in the client's approximate age
Client Address

Begin typing a street address and select from the suggested list to populate all address components. Count must be provided separately






Language and Interpretation Information





Client Immigration Information/Demographic Profile
Please provide the following demographics for your client as required by our funders. If your client does not wish to provide some of the information requested, please indicate "Chose Not to Respond."

In addition to helping us better understand the communities that we serve, providing complete and accurate information helps our staff to refer clients for other services that may be of benefit to them.

Immigration Information


Begin typing your client's country of origin. Suggested options will generate as you continue typing.

Please estimate the approximate level of education that your client received in their country of origin prior to immigration



Use this box as a reference for estimating an arrival date. Years in US will calculate based on the date that you enter above
If client's date of US arrival is unknown, please estimate a date by entering 1/1/YYYY with a year that would result in approximate number of years in the US. If a month of arrival is known, estimate a date by entering M/1/YYYY



Demographic Information

Ethnicity Hidden Fields




Begin typing the ethnicity/ethnic group that your client describes to you. Suggested options will generate as you continue typing. If the client does not wish to respond to this question or does not want to disclose their ethnicity, type and select "Chose Not to Respond."

If the client identifies with multiple ethnicities/ethnic groups, enter one ethnicity and then click "Add another ethnicity" to enter another value.

If the ethnicity that your client describes does not generate any options, leave the response as typed.




Forensic Evaluation Information and Reason for Referral

Which type of evaluation are you seeking for your client?






Please indicate the accurate court filing deadline as it would be essential for us to prioritize urgent cases

We will consider desired due dates for scheduling but cannot guarantee priority appointments. Clients are seen on a first come first serve basis except in exceptional circumstances.

Please provide any information that may be helpful to to provider conducting the evaluation such as your client’s persecution history, what you’re hoping to document through a forensic evaluation, and concerns you would like to be addressed.

The referring attorney is required to provide the clinic with a draft declaration and/or any other supporting documents to help the provider get insight on the case. This can be uploaded now as a .pdf or .doc/.docx file or emailed to the HRC at a later time. Evaluations will be rescheduled if a declaration is not received at least one week before the date of the evaluation.

Please upload any additional documents that may be helpful to the provider. Files can be uploaded as a .pdf or .doc/.docx file. If you would like to upload more than one additional file, click "Add another file" below.