Sample Client Intake Form - Catholic Legal Immigration Network, Inc.

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Race:(Check one)HispanicCaucasianAfrican-AmericanNative AmericanOtherCurrent Immigration Status: (Check one)PermanentresidentU.S. citizenWithout legal statusRefugeeDate of ALL entries into the United States:Begining with the most recent onePort of entryDid you enter with inspection?YesYesYesYesYesYesNoNoNoNoNoNoTo better serve you, please describe why you are here today and what kind of assistance you need?Please check off the boxes that apply to you:Applying for a family member?Is a family member applying for you?Interested in obtaining citizenship of this country for yourself?Renewing your work permit?Renewing or replacing your Legal Permanent Resident card?OtherHave you already consulted with another legal provider regarding your case?Who:YesIf your answer is ‘yes,” pleaseanswer who, when, and where:No124 A MANUAL BY CATHOLIC LEGAL IMMIGRATION NETWORK, INC.
When:Where:Do you have any deadlines, such as:Yes No Court datesYes No Filing deadlinesYes NoOther _____________________________Have you ever been arrested or incarcerated for any kind of offense?If your answer was “yes,” then please explain below when, where, for how long,and why?YesNoWhen:Where:For howlong:Why:Part B.List every address where you have lived for the last five years:AddressWhen did you begin livingthere?When did you leave?1.2.3.4.5.List the last address outside the United States where you lived for more than one year:Address When did you begin living there? When did you leave?Managing an Immigration Program: Steps for Creating & Increasing Legal Capacity 125
Page 1: ATTACHMENTSample Client Intake Form
Page 5 and 6: Date of Marriage:Place of Marriage:

Sample Client Intake Form - Catholic Legal Immigration Network, Inc.

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