Attorney & Professional Referral Form
Use this form to refer a client for evaluation and related services. Preserve the original wording and complete all required items before submission.
Referring Professional Information
Referring Professional Name
*
First Name
Middle Name
Last Name
Professional Role
*
Please Select
Immigration attorney
Family law attorney
Criminal defense attorney
Other attorney
Probation / community supervision professional
Civil litigation attorney
Juvenile defense attorney
Public defender
Other
Law Firm / Agency / Organization / Practice Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
Please Select
Email
Phone
Referring Professional Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Information
Client's Full Name
*
First Name
Middle Name
Last Name
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email Address
*
example@example.com
Client's Age
*
State Where Client Will Be Physically Located During the Evaluation
*
Please Select
Georgia
Florida
South Carolina
Other
If Other, Specify the State
Preferred Language for the Evaluation
Please Select
English
Spanish
Other
If Other, Specify Preferred Language
Will an Interpreter Be Needed?
Please Select
Yes
No
Unsure
If Yes, What Language Is Needed?
Evaluation Type and Context
Type of evaluation requested
*
Please Select
Immigration clinical evaluation
Court-mandated mental health evaluation
Substance use evaluation
Anger management assessment with recommendations
Unsure / need help determining appropriate service
Other
If Other, specify type of evaluation requested
General immigration matter or referral context
Please Select
Hardship / cancellation-related matter
Asylum / persecution-related matter
VAWA-related matter
U-Visa matter
T-Visa matter
Other
Briefly describe the clinical referral question or purpose of the evaluation
Which evaluation has been requested?
Please Select
Mental health evaluation
Substance use evaluation
Anger management assessment with recommendations
More than one evaluation
Unsure
Who requested or ordered the evaluation?
Please Select
Court
Judge
Attorney
Probation / community supervision
Agency
Other
Court, Agency, and Service Requirements
Is there a written court order, referral instruction, or other document describing the required evaluation?
*
Please Select
Yes
No
Unsure
Does the referring court or agency require a specific evaluator credential, approved-provider status, evaluation format, or assessment instrument?
*
Please Select
Yes
No
Unsure
If yes, briefly describe the requirement.
Is telehealth permitted for this evaluation?
*
Please Select
Yes
No
Unsure
Deadlines, Dates, and Expedited Service
Is there a deadline for the completed report?
*
Please Select
Yes
No
Unsure
Report deadline
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Is there an upcoming hearing, filing, interview, or other relevant date?
*
Please Select
Yes
No
Date of hearing, filing, interview, or other event
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Is expedited service being requested?
*
Please Select
Yes
No
Unsure
Report Delivery and Scheduling Contact
Who should receive the completed report?
*
Referring attorney/professional
Client
Another authorized professional or party
To be determined
Name and role of additional report recipient
May Empowered Transitions contact the client directly about scheduling?
*
Please Select
Yes
No — please contact me first
Other instructions
Specific instructions regarding communication with the client
Additional Participation and Review
May additional participation be requested?
*
Please Select
No
Possibly
Yes
Unsure
If yes or possibly, describe the requested participation and any known dates
Anything else we should know to determine whether this referral is appropriate
Acknowledgments
Acknowledgment of no guarantee of acceptance, findings, recommendations, or outcome
*
I acknowledge that submitting this referral does not guarantee acceptance of the case, a particular clinical finding or diagnosis, a specific recommendation, acceptance of the evaluation by a court or agency, or any immigration or legal outcome.
Acknowledgment of responsibility to verify case-specific requirements
*
I acknowledge that the referring party and/or client is responsible for verifying any case-specific requirements regarding evaluator credentials, approved-provider status, telehealth, evaluation type, testing, or other court or agency requirements before the evaluation is scheduled.
Acknowledgment of independent clinical services and no legal advice
*
I acknowledge that Empowered Transitions Counseling provides independent clinical evaluation services and does not provide legal advice or predetermined clinical conclusions.
Submit Referral
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