Attorney Referral Form printable pdf download

Attorney Referral Form

TTORNEY

EFERRAL

ORM

To refer a new client for forensic evaluation, please submit this completed form, I-589 application and

declaration via fax to 213.747.4662 or email to . Ana Deutsch, PTV’s Clinical

Director, will review for eligibility for PTV services. If you have any questions regarding a client referral,

please contact PTV’s Case Manager, Maggie Shackelford, at 213.747.4944 x 252 or via email (above).

Date: ______________________

Attorney’s Name: __________________________ Address: _____________________________

Phone: ___________________________________ Fax: _________________________________

Asylum Applicant: __________________________

A #: _________________________________

Address: __________________________________ Phone: _______________________________

Home Country: _____________________________ Interpreter needed:

Yes*

PTV’s

* If an interpreter is required, please review

Primary Language: __________________________

Interpreter Policy

(effective March 1, 2013).

INS Interview Date: __________________________

Master Calendar Hearing Date: _________________

Merits Hearing Date: _________________________

Due Date for PTV Reports: ____________________

Type of Forensic Evaluation Requested:

Psychological

Medical

Both

Special Issues (e.g.. focus of evaluation):

Attorney Referral Form