Forensic Evaluation Request Form

  • 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

  • Are you a student attorney?*

  • 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 Date of Birth (DOB)
     - -
  • Format: (000) 000-0000.
  • Client Gender*
  • Client's Preferred Pronouns*
  • Is the client currently detained?*
  • Would your client prefer to have the evaluation conducted in English or another language?*
  • Is the client applying for asylum?*
  • Please check all that apply in regards to the basis for the client's application for asylum
  • Please check all that apply to your client's case
  • Has your client agreed to be evaluated by the Upper Valley Human Rights Clinic?*

  • 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?*
  • Would you client prefer a male or female evaluator? Please note that we cannot guarantee an evaluator based on gender preference.*
  • When is the hearing date?
     - -
  • When do you need the written affidavit to be completed?*
     - -
  • We cannot guarantee that the evaluator can testify, but are you requesting oral testimony?*
  • If known, please indicate the date of testimony
     - -
  • Is a phone testimony acceptable?
  • Does your client have an active Primary Care Physician (PCP)?*
  • 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?*

  • 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.
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