Forensic Evaluation Request Form
Important Notice
At this time, we are only able to conduct evaluations for clients residing in New Hampshire or Vermont. 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 make every effort to ensure all clients have the opportunity for a forensic examination. For a full list of our policies and procedures, please visit our website at http://geiselmed.dartmouth.edu/uvhrc. Please direct any questions to uvhrc@groups.dartmouth.edu.
Attorney Contact Information
Legal Name
*
First Name
Last Name
Agency/Firm
*
Address
*
Phone Number
*
Fax
Email
*
Are you a student attorney?
*
Yes
No
Name of the supervising attorney
Email of the supervising attorney
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Client Information
Please submit a separate request for each client. Client identifying information will only be available to the asylum coordinator and members of the evaluation team on a need-to-know basis. For psychological evaluations, client identifying information is necessary to create an electronic health record (EHR) for the patient. Details regarding any forensic evaluation will NOT become part of any client electronic medical record. Any fields without a red asterisk are optional.
Client Name
Prefix
First Name
Middle Name
Last Name
Suffix
Client Date of Birth (DOB)
-
Month
-
Day
Year
Date
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone Number
Please enter a valid phone number.
Client Email Address
example@example.com
Client Gender
*
Female
Male
Non-binary/third gender
Prefer to self describe
Prefer not to say
Please enter the client's self-described gender below
Client's Preferred Pronouns
*
He/him/his
She/her/hers
They/them/theirs
Ze/Zem/Zir
Other
Is the client currently detained?
*
Yes
No
Client's Country of Origin
*
Would your client prefer to have the evaluation conducted in English or another language?
*
English
Other
What is the client's preferred language for the evaluation?
We will make every effort to provide a medical interpreter for the evaluation. However, please be prepared to provide a qualified, non-family member interpreter if needed.
Client's Current Location (City, State)
*
Is the client applying for asylum?
*
Yes
No
Please check all that apply in regards to the basis for the client's application for asylum
Race
Religion
Nationality
Membership in a social group
Political opinion
Please check all that apply to your client's case
Domestic Violence or Intimate Partner Violence
Sexual Violence
Foreign detention
Gay/Lesbian/Bisexual/Transgender
One child policy
Female genital mutilation
Sensory deprivation
Kidnapping
Slavery
Gang violence
Trafficking
Other
Has your client agreed to be evaluated by the Upper Valley Human Rights Clinic?
*
Yes
No
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Evaluation Information
Our human rights clinic is a joint effort of the Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, and Good Neighbor Health Clinic. An evaluation team will consist of physicians trained in forensic evaluation, medical students, and medical interpreters. Please note that the evaluation type will be guided by shared decision making between the Upper Valley Human Rights Clinic staff and client's legal council, based on clinic staff availability and indications for medical and/or psychiatric evaluation based on clients declaration.
What type of evaluation are you requesting for your client?
*
Comprehensive medical evaluation (includes full history, physical exam, and basic psychiatric screening evaluation by a family or internal medicine physician)
Physical evaluation only (includes full history and physical exam by a family or internal medicine physician)
Psychological evaluation only (includes full history and evaluation by a psychiatrist or psychologist)
Please specify all physical findings (e.g. scars) and parts of the physical exam (e.g. pelvic exam) that you would like us to assess and document
Please describe the psychological symptoms your client experience and/or continues to experience as a result of the trauma they suffered.
Common symptoms may include but are not limited to the following: Depression (depressed mood, loss of interest, sleep and appetite changes, decreased energy and concentration, self harm, suicidal ideation), PTSD (intrusive throughs, nightmares, flashback, disturbing memories, avoidance, hypervigilance, panic attacks, irritability, self-blame, guilt), Anxiety (mood changes, excessive worry, restlessness, fatigue, impaired concentration, irritability, decreased sleep)
Are you seeking an evaluation to help explain why a client was unable to meet the 1-year deadline to file? If so, please describe why you believe this individual was unable to file for asylum within a year of arriving in the United States.
Would you client prefer a male or female evaluator? Please note that we cannot guarantee an evaluator based on gender preference.
*
Female
Male
No preference
When is the hearing date?
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Month
-
Day
Year
Date
When do you need the written affidavit to be completed?
*
-
Month
-
Day
Year
Date
We cannot guarantee that the evaluator can testify, but are you requesting oral testimony?
*
Yes
No
If known, please indicate the date of testimony
-
Month
-
Day
Year
Date
Is a phone testimony acceptable?
Yes
No
Are you seeking an evaluation through any other organization?
*
Please Select
Yes
No
PLEASE NOTIFY UVHRC@GROUPS.DARTMOUTH.EDU IF YOU SECURE AN EVALUATION ELSEWHERE
Has your client been subjected to torture as it is defined in the United Nations Convention Against Torture?
*
Please Select
Yes
No
Definition: torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.
Does your client have an active Primary Care Physician (PCP)?
*
Yes
No
Is your client interested in being referred to other Good Neighbor Health Clinic or Dartmouth-Hitchcock Medical Center physicians for follow-up care and treatment following the forensic evaluation?
*
Yes
No
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Additional Case Details
After submitting this form, please send the client's affidavit and any other supporting documents (including medical records) that may help with the forensic evaluation to Asylum Coordinator Benjamin Wagner at Benjamin.D.Wagner.MED@dartmouth.edu.
Please verify that you are human
*
Submit
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