Evaluation Intake

Immigration Evaluation

Thank you for contacting us regarding your immigration evaluation. Before we proceed, we want to ensure you fully understand the process and feel confident in your next steps.

No-Cost Case Review – Get Expert Insight Before You Decide
We understand that committing to a psychological evaluation is a big decision. That's why we offer a complimentary written case review after you complete this intake form.

🔹 How it Works:

1. Fill out this form.

2. Once this form is completed, Dr. Long will personally review your responses, assess the relevant factors in your case, and send you a free written review of your case outlining how a formal evaluation can support your immigration application.

Important Notes:

Confidentiality: The information you provide may be included in the final report submitted to USCIS or other relevant parties. Dr. Long will ensure that only pertinent details are included to protect your privacy whenever possible.

Accuracy Matters: It is essential to provide honest and thorough responses. Any discrepancies or omissions may impact the evaluation's findings and potentially your immigration case.

How to Complete the Form:

Time Required: Set aside 45 minutes to complete the form.
Device: Use a computer for ease of completion, though any device with internet access will work.
Saving Progress: Use the 'Save' feature at the bottom of the form if you need to pause and resume later.
Answering Questions: Provide complete and accurate answers. If a question does not apply, write "N/A" instead of leaving it blank.

If you have any questions during the process, please don't hesitate to contact us at David@drlisalong.com. We're here to provide clarity and support.

Is anyone helping the applicant with this form, scheduling, payment, and reviewing the completed forms?*

YESNO

What is the name of the person assisting the applicant and helping with communication and scheduling?

First NameLast Name

How do you know the applicant?

Email of person assisting the Applicant

example@example.com

What is the applicants Given Name (First Name) ?

What is the applicants Middle Name (if any) ?

What is the applicants Family Name (Last Name)

Applicants email address*

example@example.com

Phone Number

Please enter a valid phone number.

Date of Birth*

Date

Age

What Language do you speak?*

Please enter the alien registration number (A-Number) given to you by USCIS

Please answer the following questions *

	Short Answer
What country did you migrate from?
What region or specific area?
What year did you come to the USA

Have you submitted a N-648 Form Before?

YesNo

Please tell us when you submitted the previous form and why it was rejected. You must upload a copy of the rejected form below .

Please submit the N-648 Form that was previously not accepted. If you don't have a digital copy, you can photograph each page and upload the images.

Do you have a appointment scheduled with USCIS for your naturalization interview?

YesNo

What is the date of the Appointment

Date

Have you failed the Naturalization interview in the past?

YesNo

Please tell us how many times and what portions of the test did you fail.

What is the date of your interview with USCIS

Date

Please answer the following questions *

	Yes	No
1. Are you 55 years of age or older at the time of filing for naturalization and have you lived as a permanent resident in the U.S. for 15 years?
2. Are you 50 years of age or older at the time of filing for naturalization and have you lived as a permanent resident in the U.S. for 20 years?
3. Are you 65 years of age or older and have you been a permanent resident for 20 years at the time of filing for naturalization? (Note: You may be given a shorter test using an interpreter if you meet this criterion.)
4. Do you have a US Drivers License
5. Did you apply for Asylum, Vawa, T-Visa, or U-Visa when you came to the USA

Can you share with us your reasons for coming to America?

List any medical conditions you have.

Have you visited a mental health professional in the United States or in your home country? If yes, please describe the reason for the visit and mention any treatments or diagnosis you received.

Is the applicant currently taking any prescription medicine?

YesNo

Please list any prescription medication being taken by the Applicant

Is the applicant currently working?

YesNo

Where does the applicant work and what do they do?

During the past year, have you felt any of the following ?*

	Yes	No
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
3. Feeling more irritated, grouchy, or angry than usual?
4. Sleeping less than usual, but still have a lot of energy?
5. Starting lots more projects than usual or doing more risky things than usual?
6. Feeling nervous, anxious, frightened, worried, or on edge?
7. Feeling panic or being frightened?
8. Avoiding situations that make you anxious?
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10. Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn't hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality overall?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20.Not feeling close to other people or enjoying your relationships with them?

Moving to America can be very challenging and sometimes traumatic, leading to conditions like Post-Traumatic Stress Disorder (PTSD). PTSD can greatly affect important tasks, like immigration procedures and exams, and can make learning harder. Recognizing if you have PTSD is important to help you qualify for special waivers or help. Talking about these experiences might be hard, but it's necessary for us to understand them for your evaluation.*

	Yes	No
1. Lack of basic necessities (shelter, food, or water)
2. Lack of medical care during illness or severe medical condition
3. Personal property confiscated or destroyed
4. Exposure to combat, military firefights, or war zones
5. Forced evacuation under dangerous conditions
6. Experienced or witnessed physical violence (e.g., beating, knifing, mugging)
7. Experienced or witnessed sexual violence (e.g., rape, sexual abuse)
8. Torture or systematic infliction of physical or mental suffering
9. Imprisonment, forced labor, or hostage situations
10. Extortion, robbery, or brainwashing
11. Forced to hide, kidnapped, or other forced separation from family
12. Enforced isolation, neglect, or betrayal that placed you at risk
13. Forbidden burial rites or desecration of bodies or graves
14. Forced to harm or betray others, placing them at risk
15. Loss or disappearance of a spouse, child, or other family member due to violence or kidnapping
16. Witnessed violent acts (e.g., beatings, torture, killing)
17. Witnessed sexual violence (e.g., rape or sexual abuse)
18. Natural disasters (e.g., hurricanes, earthquakes)
19. Sudden, unexpected death of a loved one
20. Severe verbal abuse, belittling, humiliation, or severe bullying

A brain injury can affect your ability to learn a new language or memorize civic information. Answer these questions*

	Yes	No
Have you ever lost consciousness after a head injury?
Have you ever been hospitalized due to a head injury?
Have you ever experienced confusion or memory loss following a head injury?
Have you ever had a seizure following a head injury?
Have you been involved in a car accident where you hit your head or were shaken violently?
Have you ever been diagnosed with a concussion?
Have you ever had a sports injury involving a blow to the head?
Have you ever fallen from a height and hit your head?
Have you been in a physical altercation where you received a blow to the head?
Have you ever experienced persistent headaches following a head injury?
Have you noticed a change in your behavior or mood following a head injury?
Have you had difficulty with concentration or attention since a head injury?
Have you been exposed to blasts or explosions during military service?

If you have previous medical records important for your evaluation, please upload them for your N-648 application. You can photograph any medical reports, doctors' notes, or previous N-648 forms. To upload, click 'Browse' and choose the files from your camera roll. You can select up to 20 photos or documents if needed. It is ok if you do not have documents to upload.

Upload a photo identification card, such as a passport or driver's license or green card.

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.