Youth Advocacy Project Referral Form

HIAS Pennsylvania

Youth Advocacy Project Referral Form

HIAS Pennsylvania will not share any information provided in this referral form. All information provided will remain confidential.

Name of Referring Person:Date:

Interpreter Used: Yes______No______Language:

Name of Interpreter:Relationship to Client:

Caseworker Information

Name:

Agency:

Title:

Address:

Phone Numbers:

Email:

Client Information

Full Name (as on official documents):

Other Names Used (including nicknames):

Date of Birth:City and Country of Birth:

Sex:Age:

Country of Citizenship:

Identity Documents in Client's Possession:

Lives with:Since:

Address:

Telephone Number:Safe to leave a message? Yes______No______

Do you attend school? Yes_____ No____If yes, where and what grade?

Do you know if anyone in your family has received help from HIAS Pennsylvania? Yes_____ No_____ If yes, what is their full name?

Information Regarding the Child's Family

Father's Name:

Date of Birth:

Place of Birth:

Is he in the United States? If yes, what is his current immigration status?

Address:

Telephone Number:

When was the last time you had contact with your father?

Mother's Name:

Date of Birth:

Place of Birth:

Is she in the United States? If yes, what is her current immigration status?

Address:

Telephone Number:

When was the last time you had contact with your mother?

Other Relatives in the United States

NameRelationshipContact Information

Other Relatives in home country?

NameRelationshipContact Information

Are you able to live with your parents? Yes___ No___ If no, why not?

Are you afraid of returning to your country of birth? Yes_____ No____ If yes, why?

Have you ever reported abuse or neglect to anyone? If yes, please explain.

Client's Immigration History

When did you enter the United States?

Where did you enter the United States?

Did you have a passport? Yes____ No_____ If yes, did you have a visa?

Alien Number:

Have you ever been detained by immigration officials? If yes, where, when and what happened?

Has anyone ever applied for immigration papers for you? If yes, please explain.

What immigration documents do you have?

Your current immigration status:

Social Security Number:

Work Authorization? Yes__ No______

Have you ever had contact with immigration officials? Yes_____ No______If yes, did you use any false identification?

Did you ever have to go to court for an immigration case? Yes_____ No____Ye If yes, explain.

Personal Criminal History

Have you ever had contact with the police (including school police)? Yes______No_____

If yes, please explain (where, date arrested, outcome of case).

Have you ever been the victim of a crime that was reported to the police? Yes_____ No_____

If yes, please explain.

Information Regarding Dependency or Guardianship

Date dependency established

Name of child advocate

Name of CountyCaseworker

Name of foster care caseworker

Was dependency based on abuse, abandonment or neglect?

Other relevant information regarding dependency:

Information Regarding Other Caseworkers and Attorneys

NameAgencyEmail