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

Has the client consented to this referral?

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

Your Relationship to the Client being Referred

Referral Source Contact Information

Your Organization

Your First Name

Your Last Name

Your Email

Your Phone Number

Client Scheduling Information

First Name(s)

Last Name(s)

Date of Birth

Is the client's official date of birth known?

YesNo

Calculated Age

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

Street

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

City

State

Zip Code

Preferred Phone Number

Alternate Phone Number

Language and Interpretation Information

Primary Language

Other Primary Language

Additional Spoken Languages

What is the client's level of proficiency in English?

Does the client require interpretation to receive services?

YesNo

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

Country of Origin

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

Level of Education Received in Country of Origin

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

Is the client's official date of arrival in the US known?

YesNo

US Arrival Date

Calculated Years in US

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

Current Immigration Status

Other Immigration Status

Date Asylum Granted

Demographic Information

Ethnicity Hidden Fields

Ethnicity Id

Client Gender

Other Gender

Ethnicity

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.

Religion

Other Religion

Employment Status

Other Employment Status

Forensic Evaluation Information and Reason for Referral

Type of Evaluation Requested

Which type of evaluation are you seeking for your client?

Client Medical Insurance Status

Other Insurance Description

Does your client have a gender preference for their provider?

MaleFemaleNo preference

Is testimony required?

YesNo

Do you have an Immigration Court Filing Deadline for this client's case?

YesNo

Immigration Court Filing Deadline

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

Desired Due Date For Evaluation

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.

Reason for Referral

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.

Declaration

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.