LAHRI/KHRC Centralized Referral Form

Direct Referral Case Submission

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. If your client is currently in detention, please give us at least 6-8 weeks to schedule the case. We will always make every effort to ensure all clients have the opportunity for a forensic examination. ***ATTENTION ATTORNEYS: please save contact@lahumanrights.org & contact@keckhumanrights.com in your email as soon as possible, so our email to you does not go into spam.
Attorney Information
Attorney Name*

First NameLast Name
Attorney Email*
Attorney Phone*

Area CodePhone Number
Attorney law firm*

Client Information
Client initials*
Client age*
Client gender*
Country of origin*
Client's location*
Type of evaluation(s) requested*

PsychologicMedicalGyn or FGMNeurological
If multiple exams are requested, which is your top priority?
Can the examination be performed virtually (e.g., over Zoom), or will the evaluation require in-person examination?*

In-personVirtual
What is the client's primary language*
Our clinics require that you provide an interpreter if needed. Do you agree to this?*

YesNo

Direct Referral Case Submission