Individual Intake Form

In partnership with Immigrant Legal Resource Center (ILRC) and DreamActivist, E4FC offers individual analysis of possible immigration remedies for qualifying immigrant youth in the United States. To be eligible for this confidential and anonymous service, you must fulfill ALL of the following: * You must have arrived in the United States at least four (4) years ago * You must have arrived in the United States before the age of 16 * You must be under age 35 Please remember that the feedback provided by this service should never be a substitute for a face-to-face consultation with an immigration attorney. This service should only be used for a preliminary analysis of your possible immigration remedies. We urge you to consult with a reliable immigration attorney for a comprehensive analysis. Consultations with attorneys or legal service providers are completely confidential. For a list of free legal services, visit http://www.justice.gov/eoir/probono/states.htm. Due to demand for this service, it may take up to two months for us to process your case. If you have questions about this service or require immediate attention, please email our Case Analysis Team at intake@e4fc.org. For more information about Educators for Fair Consideration (E4FC), please visit us online at www.E4FC.org.

* Required

GENERAL INFORMATION

NAME * First name only is fine, if you prefer.

EMAIL * Please provide a valid email address.

EMAIL (Confirmation) * Please confirm the email you provided above.

TELEPHONE * Please provide a telephone number so we can contact you, if necessary.

STATE OF RESIDENCE * Please provide state where you currently reside.

ZIP CODE * Please provide zip code where you reside currently.

COUNTRY OF ORIGIN * Please provide the country where you were born.

DATE OF BIRTH * To be eligible for this service, you must be under age 35. Please enter month, day, and year (i.e. 12/12/1987)

YOUR EXPERIENCE WITH LEGAL ASSISTANCE

What attracted you to THIS Case Analysis Service? * Please answer any and ALL that apply.

Cost: It's free
Accessibility: It's online
Anonymity: You don't know me
Confidentiality: You won't tell anyone about my case
Quality: I heard the service is reliable
Familiarity: I know people who've used this service
Other:

Have you (or someone else in your family) ever received professional legal assistance? *

Yes
No
Not sure
Other:

If YES, what kind of professional legal assistance did you receive? Please check any and ALL that apply.

Immigration attorney (abogado)
Non-profit law clinic
Immigration consultant (notario)
Other:

If YES, how satisfied were you with the professional legal assistance you received? Please check all that apply.

	1	2	3	4	5
Very satisfied						Not satisfied

If NO, why haven't you sought out professional legal assistance? Please check any and ALL that apply.

Money: I think it will cost too much money.
Fear: I'm afraid to talk to someone about my situation.
Lack of Information: I don't know where to find one
No need: I don't need professional legal assistance.
Other:

ENTRY AND RE-ENTRY TO THE U.S.

DATE OF ENTRY * To be eligible for this service, you must have first entered the U.S. at least four years ago (2006 or before).

Has it been more than 10 years since you first entered? *

Yes
No
Not sure

Did you enter with a VISA? * For example, "Visa B - Tourist Visa"?

Yes
No
Not sure

If you entered with a visa, is your visa still VALID? Valid = Not Expired

Yes, my visa is still valid (it has not expired)
No, my visa is not valid (it has expired)
I'm not sure if my visa is valid

Did you enter ILLEGALLY? *

Yes
No
Not sure

Have you traveled outside the U.S. (even for a short period of time) since you first entered? *

Yes
No
Not sure

If so, list EACH trip you made outside the country. Provide date of departure, date of re-entry, and whether you re-entered with a visa.

FAMILY AND SIGNIFICANT OTHERS

Are either of your PARENTS U.S. Lawful Permanent Residents (LPRs)? * Do either of them have green cards?

Yes
No
Not sure

Are either of your PARENTS U.S. Citizens? *

Yes
No
Not sure

Are any of your CHILDREN U.S. Lawful Permanent Residents (LPRs)? * Do any of them have green cards?

Yes
No
Not sure

Are any of your CHILDREN U.S. Citizens? *

Yes
No
Not sure

If any of your CHILDREN are Lawful Permanent Residents (LPRs) or U.S. Citizens, please list their AGES.

Are any of your SIBLINGS Lawful Permanent Residents (LPRs)? * Do any of them have green cards?

Yes
No
Not sure

Are any of your SIBLINGS U.S. Citizens? *

Yes
No
Not sure

If any of your SIBLINGS are U.S. Lawful Permanent Residents (LPRs) or U.S. Citizens, please list their AGES.

Are any of your AUNTS OR UNCLES Lawful Permanent Residents (LPRs)? * Do any of them have green cards?

Yes
No
Not sure

Are any of your AUNTS OR UNCLES U.S. Citizens? *

Yes
No
Not sure

Are any of your GRANDPARENTS U.S. Lawful Permanent Residents (LPRs)? * Do any of them have green cards?

Yes
No
Not sure

Are any of your GRANDPARENTS U.S. Citizens? *

Yes
No
Not sure

Are you married? *

Yes
No

If you're married, is your SPOUSE a Lawful Permanent Resident (LPR)? *

Yes
No
N/A: I'm not married

If you're married, is your SPOUSE a U.S. Citizen? *

Yes
No
N/A: I'm not married

Do you have a GIRLFRIEND or BOYFRIEND? *

Yes
No

If you have a GIRLFRIEND or BOYFRIEND, is he or she a Lawful Permanent Resident (LPR)? * Does he or she have a green card?

Yes
No
N/A: I do not have a boyfriend or girlfriend

If you have a GIRLFRIEND or BOYFRIEND, is he or she a U.S. Citizen? *

Yes
No
N/A: I do not have a boyfriend or girlfriend

Are you a member of the LGBTQ community? *

Yes
No
Prefer not to state

EDUCATION AND CAREER

Did you graduate from HIGH SCHOOL in the U.S.? *

Yes
No

If you did NOT graduate from high school, did you obtain your GED? *

Yes
No
N/A: I graduated from high school

Have you attended COLLEGE in the U.S.? *

Yes
No

If yes, what TYPE of COLLEGE? *

Community or Junior College (2 - year)
College / University (4 - year)
Technical / Professional School
N/A: I have not attended college in the U.S.

If yes, have you obtained a DEGREE? *

If yes, WHAT COLLEGE are you attending (or did you attend)?

If yes, what is (or was) your MAJOR?

What CAREER/PROFESSION are you planning to pursue?

VISA PETITIONS

Has a relative or employer ever filed a PETITION for you or your parents? *

Yes
No
Not sure

If it was a relative, what is your relationship to that relative? Was It your parent, sibling, aunt/uncle, grandparent, etc.?

If yes, was the petition filed BEFORE May 1, 2001? *

Yes
No
Not sure
N/A: No petition was filed

If yes, when was the petition filed (what was the exact year)? Leave blank if you don't know

If yes, were YOU included on this petition? *

Yes
No
Not sure
N/A: No petition was filed

Did your petition get accepted by USCIS (formerly known as INS)? Usually INS or USCIS sends you or your parents a confirmation of your petition. Leave blank if you don't know

MISCELLANEOUS

Have YOU ever been the VICTIM OF A SERIOUS CRIME in the U.S. which you reported to the police? * Examples of serious crimes include domestic violence, robbery, physical attack.

Yes
No
Not sure

Have either of your PARENTS ever been the VICTIM OF A SERIOUS CRIME in the U.S. which they reported to the police? * Examples of serious crimes include domestic violence, robbery, physical attack.

Yes
No
Not sure

Have any of your SIBLINGS ever been the VICTIM OF A SERIOUS CRIME in the U.S. which they reported to the police? * Examples of serious crimes include domestic violence, robbery, physical attack.

Yes
No
Not sure

If one of your SIBLINGS was the VICTIM OF A SERIOUS CRIME in the U.S., how old is that sibling? Leave blank if you don't know

Have you ever been in FOSTER CARE? *

Yes
No
Not sure

Are you AFRAID OF RETURNING to your home country? *

Yes
No
Not sure

If yes, please elaborate. Reasons to be fearful could include: politics, race, religion, sexuality, group affiliations, etc.

CONTACT WITH LAW ENFORCEMENT AND/OR I.C.E.

Have you ever been in IMMIGRATION COURT? *

Yes
No
Not sure

Have you ever been ARRESTED or been in contact with I.C.E. or law enforcement? *

Yes
No
Not sure

If yes, please describe what happened.

Have you ever been SENT BACK to your home country by immigration authorities (ie. I.C.E.)? *

Yes
No
Not sure

Have you ever been (or are you currently) in DEPORTATION/removal proceedings? *

Yes
No
Not sure

If you are currently in deportation / removal proceedings, please provide your ALIEN REGISTRATION NUMBER (A#).

If you are currently in deportation / removal proceedings, when is your next court date?

REFERRALS

Do you have a friend or family member who is currently in detention and is eligible for this service? *

Yes
No
Not sure

If so, can you help us make contact with him or her? *

Yes
No
Not sure
N/A: I do not have a friend or family member who is currently in deportation and is eligible for this service.

QUESTIONS AND ADDITIONAL INFORMATION

QUESTIONS Do you have any specific questions related to your immigration case?

ADDITIONAL INFORMATION Please provide any additional information that would help us analyze your immigration case.

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