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Intake Form
INTAKE FORMFORMULARIO DE ADMISION

Intake Form

Name*:
First Name*
Lastname*
Current Address*:
Street (With house or apt #)
City *
State *
Postal Code *
Telephone No.*:
Work Phone No.*:
E-Mail Address: *
Do you give consent to contact by email?
Your Date of Birth: *:
Place of Birth (City, State & Country)*:
City*
State*
Country*
U.S. Social Security No.:
Date you became a Permanent Resident:
Alien o “A” #:
Country of Nationality:
Marital Status:
Where have you lived the last 5 years:
 
Place:
 
From:
 
Until:
Where have you worked the last 5 years:
 
Place:
 
From:
 
Until:
All trips taken outside the U.S. the last 5 years:
 
To Where:
 
From:
 
Until:
U.S. IMMIGRATION HISTORY & CURRENT STATUS::
Are you currently present inside the U.S.*:
If yes, how many times have you entered the U.S.?
Have you ever remained in the U.S. past the date of your authorized stay?
Current Visa Status:
I-94 Date of Expiration:
I-94 Number:
Type of visa used on last entry:
Employment Authorization Document (EAD) expiration date:
Were you inspected (with passport, visa, etc.) on your last entry to the US? *
Have you ever been arrested, charged or cited in the U.S.A. or in any foreign country?*:
If so, how many times? For each arrest, please explain the details
Have you ever been in the deportation process? *
 
If yes, please explain (in which court, etc.):
Are you afraid to return to your country?*
Yes ? Explain
Have you ever been a victim of a crime in the United States (including domestic abuse)?*
If Yes? Explain
Has any immigration petition or application been filed on your behalf - either by you or someone else?
If yes, please detail what type of petition(s), the date(s) filed, and where filed:
Type
Date
Place
Highest Level of Education:
DEPENDENT INFORMATION:
Spouse
Are you legally married? *
Name of Your Spouse:
 
Place of Birth:
City
State
Country
 
Place of Marriage:
 
Date of Marriage:
 
Nationality of Spouse:
 
If he/she was naturalized, date of permanent residence or naturalization:
 
Immigration Status in the U.S.:
 
Alien or “A” #:
 
Previous Marriage(s):
Children
If you have children (including stepchildren), how many?
Parents
Are either of your parents a legal permanent resident or U.S. citizen?
Please write down your parents' information. If one or both are deceased, indicate the date of his or her death.
 
Your:
Your Spouse's
Mother's name:
 
Date of birth:
 
Place of birth:
City
City
 
State
State
 
Country
Country
 
Current Home Address:
 
If deceased, Date of Death
Father's name:
 
Date of birth:
 
Place of birth:
City
City
 
State
State
 
Country
Country
 
Current Home Address:
 
If deceased, Date of Death
Do you have other family members with legal status in the US (e.g. siblings)?
 
Please name which family member, their relationship to you and their immigration status:
Name *
Signature *

Please be advised that I will proceed with the processing of your case based on the information provided in this data sheet. I assume that the information provided is accurate and complete. If there are any material changes with respect to the information you have provided on this form while your case is being processed by my office, it is your responsibility to notify me with respect to these changes. Failure to provide accurate and updated information may result in delays in processing your case and or denial of immigration benefits by U.S. Citizenship and Immigration Services.

Thank you. We look forward to assisting you with your case.

 
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