Evaluation Intake

Immigration Evaluation Intake Form

Dr. Long’s Online Immigration Evaluation Service

About Dr. Long:

Dr. Long specializes in conducting psychological evaluations for immigration purposes such as asylum, hardship waivers, VAWA, and medical disabilities under Form N-648. She is fluent in Spanish and proficient in Arabic and Russian. With over 400 psychological evaluations completed for numerous legal matters, Dr. Long has testified in federal immigration cases to support applicants.

How the Evaluation Works:

Dr. Long conducts thorough immigration evaluations online, licensed in 41 states. Each evaluation, requiring a stable internet connection and a camera-equipped device, involves a comprehensive 2-4 hour interview. The process culminates in a detailed psychological report, ranging from 8-20 pages depending on the type of evaluation. The total cost of the evaluation is $2,200, with a $1,100 deposit needed to schedule your appointment. The balance is due after you and your lawyer review the draft report and before receiving the final signed copy.

Interpreter Requirements:

For immigration evaluations, the law requires an independent interpreter to ensure accuracy and impartiality, even if Dr. Long speaks your language. This is crucial for maintaining the integrity and fairness of the evaluation. If you already have an interpreter, they can either be physically with you or join via a video call. If you need us to provide an interpreter, we will handle all aspects of scheduling and ensure that the interpreter is integrated into the video conference for the duration of your evaluation. There is an additional fee of $200 for this service, facilitating clear and effective communication throughout the process.

Scheduling Your Evaluation:

To initiate scheduling, please fill out the provided form, which may take 1-2 hours to complete. Assistance from friends or family is encouraged if necessary. After form submission, you’ll receive a link to pay the deposit. Once we confirm your payment, Dr. Long will offer three options for the date and time of your evaluation; select what works best for you. Reports are typically ready within two weeks post-evaluation, with expedited services available for an additional fee.

The more information you provide, the better your chance of a successful application!

We have intentionally created open-ended questions to give you the opportunity to explain your situation in detail. The more information you can provide to Dr. Long, the better equipped she will be to identify the legal areas that may support your case. There may be hardships that you haven't considered or realized are relevant, but Dr. Long can only identify these if you provide her with comprehensive information. Please take your time and answer each question as thoroughly as possible, including any details you think might be important for understanding your unique circumstances.
Safety Protocol

Please note that our forms do not send an automatic copy of your intake responses to protect your privacy. We use email solely for payment and scheduling communications.
What is Your First Name ?
What is your Last Name ?
Date Of Birth

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.
Email
example@example.com
What Language do you speak?
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
English Ability
Your Immigration History
What is your country of origin?
In which region, province, or state of your country were you born?
When did you first arrive in the United States?

MonthDayYear
Date
Please provide a detailed account of how you first entered the United States. Include information about the type of visa you used or the method of entry if you did not have a visa. Explain the circumstances that led to your decision to come to the U.S. You are still be eligible to file for VAWA relief even if you entered the country without legal status. Your method of entry does not disqualify you from seeking protection under VAWA. The most important aspect is to provide an honest and complete account of your experiences, regardless of your immigration status.
Your Relationship with the U.S. citizen or permanent resident who subjected you to abuse.
What is their name?

First NameLast Name
What is {usCitizen} Status

Lawful Permanent Resident (LPR)U.S. Citizen
How old are they?
What is your current relationship status with {usCitizen}?

MarriedSeperatedDivorced
Do you still live with {usCitizen}?

YesNo
The Beginning of Your Relationship

It is very important to provide long and detailed answers to the following relationship questions.
Estimated date you first communicated with {usCitizen} ?

MonthDayYear
Date
Where and how did you first meet them?
What was your first impression of them?
Can you recall your first few dates? What activities did you do, and what conversations stood out?
What interests and values do you share?
What were some of your favorite qualities or traits about them in the beginning ?
At what point did you realize that this relationship was becoming serious? Were there specific moments or conversations that indicated a deeper commitment?
Please take a moment to reflect on the early stages of your relationship with your abuser. Can you pinpoint a specific moment, event, or conversation when you first realized that your feelings had grown from simply liking this person to loving them? Describe that turning point in as much detail as you can, sharing any thoughts, emotions, or experiences that led to this realization.
When did you introduce each other to your respective families and friends? How was the relationship received by them? You may also explain why introductions did not happen.
Decision to move in with {usCitizen}
Please describe the events and conversations that led to your decision to Live Together.
Provide the address of the place you lived together.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the date that you begin sharing a residence?

MonthDayYear
Date
Engagement and Marriage History
Did you decide to have an engagement? If so, how did that proceed? Was there a celebration, and who proposed? If you skipped the engagement and went straight to getting married, that's fine—please explain.
If you had a wedding or commitment ceremony, can you describe the planning process, including choosing a date, venue, and guest list? If you did not have a ceremony, can you explain why?
What were the key factors that influenced your decision to marry? Did you have discussions about your future life together, such as where you would live, career plans, and family planning?
Date of Marriage

MonthDayYear
Date
How did your family and friends feel about the marriage?
How did {usCitizen} Family and friends feel about the marriage?
Have you engaged in joint legal or financial commitments, such as opening a bank account together, co-signing a lease, or buying property?
Date of Separation if Applicable

MonthDayYear
Date
Date of Divorce if Applicable

MonthDayYear
Date
Married Life
Looking back, can you identify a specific moment or event when you first began to feel that your marriage was becoming unhealthy or abusive? Please describe that moment in detail, sharing any incidents, conversations, or realizations that led you to question the state of your relationship. How did your abuser's behavior change, and how did you respond emotionally and practically to these changes?
As your marriage continued, can you describe any patterns of behavior or escalation in the abuse that made you realize the situation was not improving? Please provide examples of specific incidents or cycles of abuse that occurred, and discuss how these experiences affected your mental and physical well-being, your daily life, and your perception of your relationship.
Did you ever attempt to seek help or support regarding the unhealthy aspects of your marriage? If so, please describe those attempts, including any conversations with friends, family members, or professionals, and how your abuser responded to these efforts. If you did not seek help, please share any fears, barriers, or challenges that prevented you from doing so.
Can you identify a turning point or final incident that led you to decide to leave your abuser or end the marriage? Please provide a detailed account of this event, including any specific actions, threats, or realizations that motivated your decision. Discuss any steps you took to protect yourself and any challenges you faced in the process of leaving or separating from your abuser.
History of Abuse
Before starting, it's important to understand that this assessment is crucial for collecting detailed information about your history of abuse for a VAWA application. Abuse of any kind is not tolerated. We will explore different types of abuse. Even if many of your answers are "no," it doesn't mean your VAWA application will fail. The goal is to gather as much relevant information as possible. Sometimes, what constitutes abuse may not be immediately recognized, so we cover a broad spectrum of situations. Remember, there's no set level of abuse required for your case to be considered valid. Your answers are confidential and will only be used for your VAWA petition. This assessment helps ensure that all abuse aspects are addressed in the application. Please answer honestly and take your time.

If you feel more comfortable discussing these topics during your evaluation instead of writing them down, that's perfectly fine. You may leave these questions or any long-form answers blank and we can go over them in person during your session
When did the abuse start in the relationship.
Was there a pattern to the abuse? For example, did it occur only when they were intoxicated or were there any specific triggers for the abuse? Please provide as much detail as possible.
Documentation of Abuse

We recognize that victims of abuse often face significant challenges and risks when considering whether to disclose their experiences to others. There are many reasons why someone might not feel safe or able to report abuse, seek help, or document their experiences. Our goal is to document all available information thoroughly and compassionately, understanding that the absence of certain actions or evidence does not diminish the validity of your experience. Your safety and comfort are our primary concerns as we gather this information

Reporting Of abuse

	Yes	No
Have you ever discussed the abuse with anyone else, such as friends, family, or colleagues?
Did you ever report the abuse to law enforcement or any other authorities?
Did you seek medical care for any injuries or health issues resulting from the abuse?
Have you ever documented the abuse in any way, like photographs, journal entries, emails, or text messages?
Did you seek support from any organizations, support groups, or counselors regarding the abuse?
Do you know others that I've been abused by them in the past?
Are you aware of any legal charges against them, such as assault, threats, restraining orders, or domestic violence, related to your relationship or their previous relationships?

Physical Abuse History:

	Yes	No
Has physical abuse occurred more than once?
Has physical abuse occurred more than five times?
Has physical abuse occurred more than ten times?
Has physical abuse occurred more than twenty times?
Has physical abuse occurred too many times for you to accurately count?
Have you ever needed medical attention due to the physical abuse?
Has the abuse ever involved being thrown against a wall or to the floor?
Has the abuse ever involved being burned?
Has the abuse ever involved being cut or stabbed?
Has the abuse ever resulted in broken bones?
Has the abuse ever resulted in internal injuries?
Have you ever been choked or strangled during incidents of physical abuse?
Have you ever lost consciousness due to physical abuse?
Has a weapon ever been used against you during physical abuse?
Have you ever feared for your life due to the physical abuse?
Has more than one person ever been involved in physically abusing you?
Has someone else ever witnessed the physical abuse against you?
Has a child ever been present during incidents of physical abuse?
Have there been incidents where pets have also been physically abused?
Has physical abuse ever occurred in public places?
Has the abuser ever physically harmed a family member to intimidate or control you?
Has the abuser ever physically harmed a close friend to manipulate or threaten you?
Has the abuser ever physically harmed a child you care for to punish or control you?
Has the abuser ever physically harmed a pet you care for to intimidate or control you?
Has the abuser ever physically harmed a coworker or acquaintance to isolate or manipulate you?

Psychological Abuse History

	Yes	No
Have they ever belittled or humiliated you in private?
Have they ever belittled or humiliated you in public?
Have they ever used derogatory or insulting names to address you?
Have they ever yelled or screamed at you excessively?
Have they ever made you feel worthless or inferior?
Have they ever blamed you for their own abusive behavior?
Have they ever made fun of your accomplishments or dreams?
Have they ever ridiculed your physical appearance?
Have they ever mocked your religious or cultural beliefs?
Have they ever made you feel guilty for spending time away from them?
Have they ever restricted you from seeing friends?
Have they ever restricted you from seeing family?
Have they ever monitored your movements or checked your phone without consent?
Have they ever controlled your access to financial resources?
Have they ever prevented you from working or going to school?
Have they ever insisted on accompanying you everywhere you go?
Have they ever isolated you from your community or religious group?
Have they ever dictated what you can wear or how you can act?
Have they ever taken away or hidden your personal identification?
Have they ever denied you medical care or treatment?
Have they ever threatened to deport you or withdraw immigration support?
Have they ever threatened to harm themselves if you leave or seek help?
Have they ever made false accusations against you to authorities?
Have they ever threatened to harm your loved ones?
Have they ever used your children as a means to control or manipulate you?
Have they ever threatened to take your children away from you?
Have they ever coerced you into committing illegal acts?
Have they ever filmed or photographed you without your consent for blackmail?
Have they ever threatened to expose your secrets or personal information?
Have they ever denied events that you know happened?
Have they ever made you doubt your own memory or sanity?
Have they ever trivialized your feelings or your reactions to their abuse?
Have they ever made you feel like you're overreacting to their behavior?
Have they ever accused you of being the abusive one?
Have they ever given you the silent treatment to punish you?
Have they ever manipulated facts to make you question your perception?
Have they ever told others you're crazy or unstable?
Have they ever made you apologize for things that aren't your fault?
Have they ever made you doubt your own thoughts and feelings?
Have they ever used your immigrant status to belittle or control you?
Have they ever used cultural or religious norms to justify their abuse?
Have they ever isolated you by limiting your ability to speak or learn the local language?
Have they ever leveraged your lack of familiarity with the local legal system against you?
Have they ever threatened to or actually reported you to immigration authorities?
Have they ever used your lack of local support network against you?
Have they ever used your educational background to demean you?
Have they ever threatened to shame you in your community?
Have they ever threatened to reveal your immigration status to others?
Have they ever made you perform cultural or religious practices against your will?

Financial Abuse History

	Yes	No
Have they ever controlled all the finances and restricted your access to money?
Have they ever prevented you from working or earning money?
Have they ever taken your earnings against your will?
Have they ever denied you basic necessities like food, clothing, or shelter?
Have they ever run up large debts in your name without your consent?
Have they ever withheld child or spousal support as a means of control?
Have they ever forced you to provide them with your financial passwords or PINs?
Have they ever used your financial obligations or debts to control your actions?
Have they ever threatened to report you to credit agencies or other financial institutions?
Have they ever sabotaged your attempts to improve your financial situation, such as educational opportunities or job interviews?

Controlling Behavior Abuse History

	Yes	No
Have they ever followed you or showed up uninvited at places you frequent?
Have they ever used GPS or other tracking devices to monitor your whereabouts?
Have they ever made unwanted visits to your workplace?
Have they ever contacted or questioned people you know to find out about you?
Have they ever monitored your online activity or social media profiles?
Have they ever restricted you from leaving the house without them?
Have they ever taken your car keys, public transit passes, or other means of transportation to control your movements?
Have they ever physically restrained you to prevent you from leaving?
Have they ever hidden or taken away your personal identification to restrict your movement?
Have they ever dictated when you can come and go from your residence?
Have they ever sent you excessive texts, calls, or emails to check up on you?
Have they ever harassed you with incessant questioning about your activities or whereabouts?
Have they ever embarrassed or humiliated you publicly online or through social media?
Have they ever spread false rumors or malicious gossip about you?
Have they ever sent you unsolicited explicit material or threatening messages?
Have they ever used scare tactics to make you feel unsafe or paranoid?
Have they ever made veiled threats involving your safety or reputation?
Have they ever manipulated mutual friends or family to spy on you?
Have they ever used intimidation tactics to discourage you from seeking help?
Have they ever displayed aggressive behavior to make you feel unsafe even when not being physically violent?

Sexual Abuse History

	Yes	No
Have they ever forced you to engage in sexual activities against your will?
Have they ever used physical force to compel you into sexual acts?
Have they ever threatened you into performing sexual acts?
Have they ever coerced you into sexual activities by threatening to withdraw immigration support?
Have they ever ignored your requests to use protection during sexual activities?
Have they ever used emotional or psychological pressure to coerce you into sexual acts?
Have they ever insisted on sexual activities as a "proof" of love or commitment?
Have they ever made you feel guilty or ashamed for refusing sexual activities?
Have they ever recorded sexual activities without your explicit consent?
Have they ever used explicit photos or videos to blackmail you?
Have they ever treated you like a sexual object?
Have they ever made derogatory comments about your body during sexual activities?
Have they ever humiliated you during sexual activities?
Have they ever disregarded your sexual boundaries or limits?
Have they ever initiated sexual activities while you were asleep or incapacitated?
Have they ever exposed you to sexually transmitted infections knowingly?
Have they ever involved other individuals in sexual activities without your consent?
Have they ever used your immigration status to manipulate you into unwanted sexual activities?

Background Information

Answer these questions about your childhood and give us much information as you can.
How would you describe your childhood? What were some of the good and bad things about it?*
Please describe your relationship with your mother, stepmother, or a significant female role model during your childhood. How well did you get along with them when you were growing up, and how is your relationships with them now? Where do they live?
Please describe your relationship with your father, stepfather, or a significant male role model during your childhood. How well did you get along with them when you were growing up, and how is your relationships with them now? Where do they live?
How did your mother and father get along? What was their relationship like?
What was school like for you? What is the highest level of education you completed?
What kind of work did you do in your country before coming to the United States?
What kind of work have you done since coming to the United States

Please answer the following questions about your childhood before you turned 18

	Yes	No
Did you ever experience physical abuse as a child?
Were you ever neglected or left without necessary care during your childhood?
Did you witness domestic violence in your home as a child?
As a child, were you ever subjected to emotional or psychological abuse?
Did you lose a parent or caregiver through death or separation during your childhood?
Was a member of your household addicted to drugs, alcohol, or any other substance during your childhood?
Was anyone in your household incarcerated while you were a child?
Did you experience bullying or severe teasing from peers during your childhood?
Were you ever homeless or did you face extreme poverty as a child?
Did a family member have a mental illness that affected your childhood home environment?

Please provide details and information for any questions you answered "yes" to above.
Impact of Abuse on Your Life
Who you were before the abuse: Describe your personality, daily life, mental and emotional state, relationships, and any significant aspects of your well-being prior to the abuse.
Who you are after the abuse: Detail the changes in your personality, daily life, mental and emotional state, relationships, and overall well-being as a result of the abuse. Be specific about any symptoms or challenges you are experiencing.
How you feel the abuse has impacted you: Explain in detail how the abuse has affected your mental health, emotions, physical health, and overall quality of life. Include any specific symptoms such as anxiety, depression, sleep disturbances, changes in appetite, or other relevant experiences.
Mental Health

Please give as much detail as possible in your answers.
Please describe any mental health therapy, counseling, or other forms of treatment you received before the abuse, including services in your home country or in the United States. Be sure to include details such as the type of service, duration, provider or institution, and the reason for seeking these services.
Please describe any mental health therapy, counseling, or other forms of treatment you received after the abuse, including services in your home country or in the United States. Be sure to include details such as the type of service, duration, provider or institution, and the reason for seeking these services.
Are you currently taking any medication for mental health or seeing a psychologist or therapist?

YesNo
Please tell me who you are seeing for mental health and what mental health medication's you are taking.
Physical Health
Please tell me about your physical health history, including any major illnesses, injuries, or surgeries you have experienced. If you have any chronic or ongoing health conditions, please describe those as well. How have these health issues impacted your life?
Are you currently taking any medication for your physical health or seeing a doctor regularly?

YesNo
Please tell me who your medical Doctor is and what medications you are taking.
Relationships before your Marriage to {usCitizen}
If you have been previously married and divorced, please detail each marriage. Include the duration of the marriage and the reason it ended.*
Could you describe any instances of domestic violence that occurred in your previous relationships? Please include any relevant details you're comfortable sharing.*
Do you have any children, including biological children, adopted children, or stepchildren? If so, please provide their names, ages, and where they currently live.*
Is there any additional information you would like Dr. Long to know about that hasn't been covered already?
Document Submission for VAWA-Related Psychological Evaluation

We recognize the challenges in gathering supporting documents under difficult circumstances. If you are unable to provide any documents, please know that it’s okay. However, if you have any evidence of abuse, battery, or extreme cruelty that you experienced, sharing them can be helpful for your evaluation.

Marriage Related Records:
- Text messages or letters exchanged with your spouse.
- Photographs or videos from your wedding or other meaningful events.
- Joint financial or legal documents (e.g., bank statements, lease agreements).
- Marriage and divorce legal documents.
- Receipts or communication about the wedding or ceremony event or planning.
Abuse Related Records:
- Police reports or records of incidents, if available
- Medical records showing injuries related to abuse
- Any relevant legal documents or court orders
- Emails, texts, or other communications that demonstrate abuse or cruelty
- Photographs that show injuries or other evidence of abuse
- Statements or affidavits from people who are aware of your situation
If your documents aren’t in a digital format, please take pictures using your phone and upload them to our platform. You can upload up to 20 files, with each file not exceeding 100 MB. You can select multiple files simultaneously or add them one by one. Click 'Browse Files' to begin uploading.

Please be assured that your privacy is paramount. All information will be securely handled and used only for your evaluation. If you currently do not have any documents, you may still proceed with the evaluation and provide the documents at a later stage.
Cancelof
By signing this document, I acknowledge that the forensic psychologist conducting this evaluation is not serving as my personal therapist, and this evaluation does not constitute psychological treatment. The role of the psychologist is to collect information, conduct assessments, and provide an objective opinion based on their professional findings. I consent to participate in this evaluation, which may include interviews, psychological testing, and the review of relevant records. I understand that the information I provide will be used to prepare a report. This report will be shared with my attorney, immigration authorities, and possibly other relevant parties involved in my immigration case. I declare that all information provided in this form and any accompanying documents is true and accurate to the best of my knowledge. Dr. Long is an impartial evaluator, not an advocate or attorney, tasked with conducting a psychological evaluation for immigration purposes. Providing truthful information is essential for the accuracy and validity of the evaluation. I acknowledge that all information provided during this evaluation is considered confidential. It will be communicated only to my attorney or included in the evaluation report as part of my immigration application. The confidentiality of this information is maintained, except as required by law or as necessary for the immigration application process.

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Immigration Evaluation Intake Form

Safety Protocol

Your Immigration History

Your Relationship with the U.S. citizen or permanent resident who subjected you to abuse.

The Beginning of Your Relationship

Decision to move in with {usCitizen}

Engagement and Marriage History

Married Life

History of Abuse

Documentation of Abuse

Background Information

Impact of Abuse on Your Life

Mental Health

Physical Health

Relationships before your Marriage to {usCitizen}