Direct Referral Case Submission

Please note: cases with an affidavit deadline of less than 4 weeks can be very difficult to place. Please try to submit cases with a deadline as far in advance as possible. We will always make every effort to ensure all clients have the opportunity for a forensic examination.

Instructions

  1. Complete the Direct Referral Form Below

  2. Our team will contact you within 2 business days to let you know if we can accommodate your case

  3. If we accept the case, please complete PHR’s intake form here https://www.tfaforms.com/4642108. Check the box at the top that says, “clinic direct referral” rather than “PHR request” and choose our clinic (Los Angeles Human Rights Initiative, UCLA Asylum Clinic) from the dropdown menu.

  4. A case scheduler from our team will reach out to you to begin the scheduling process

Direct Referral Form

Please note, this is not a secure form. Do not provide any identifying details (Client names, DOBs, etc) here.

Attorney Name *
Attorney Name
Attorney Phone *
Attorney Phone
Is the client in detention? *
If yes, specify where in the comments section
Type of evaluation(s) requested *
Often, multiple aspects of a client's history can be evaluated in a single evaluation. If you are requesting multiple evaluations (i.e. complete medical and complete psychological), please make that clear in the final comments section at the end and explain why you believe two evaluations are needed.
Grounds for Asylum Claim *
Please specify in the comments if not listed here
Will you be able to provide an interpreter if required? *
Please note, we do not provide interpreters. It is your responsibility as your client's lawyer to provide that service.
Does your client consent to have up to 2 (total) student learners and/or clinician in training present at the evaluation *
Please obtain verbal consent from your client before submitting this form. Our clinic pairs medical students or residents with licensed clinicians to conduct cases. If they do not consent, you may need to submit your request directly to PHR or contact us for other options
If known, please indicate the date of the hearing
If known, please indicate the date of the hearing
If not known, leave blank, but please give us a general idea in the comments section
Deadline for the final affidavit *
Deadline for the final affidavit
Please select a date, this helps us with choosing the correct provider. Elaborate further in the comments section at the end if needed.
Would your client be able to have the evaluation performed on campus at UCLA?
We have access to spaces that can be used for evaluations in Westwood.
This is not a requirement, but it can help
Please indicate if you are submitting this case to any other organization so that we can properly coordinate with them.
If other, please provide that information in the additional comments section at the end of this form.
Please include why asylum is being sought, the client's relevant history, especially physical or psychological signs that related to why you are seeking a forensic evaluation and how an evaluation will benefit your client. Also include any additional information about the case that would be useful so that we can assign an appropriate clinician Do not use this space to elaborate on answers to above questions. Please use the final comments section below for that.
Please elaborate here on any additional information that is relevant or that was not addressed in the above form.
Has your client consented to an evaluation by a PHR/LAHRI member *
By consenting to an evaluation, your client grants PHR/LAHRI permission to use information gained from the evaluation in its advocacy efforts to fight persecution around the world. All information will be de-identified and data aggregated for inclusion in PHR/LAHRI reports and materials. PHR/LAHRI will never disclose your client’s name, A-number, or any other identifying information without his or her express written permission. Email contact@lahumanrights.org with any questions.