Referral Form

Attorneys and Community Partners* can complete this form to submit a referral directly to our office.

*(Community Partners can leave any section blank if not known or applicable).

If you are an individual looking for our services please click on Contact Us.

Client Information - (Please specify full name(s) as you would like them to appear in the report)

1. Name(s) of all household members:

2. Name(s) of client(s) for whom the evaluation is supporting:

3. List of individuals/qualifying members to be evaluated:

Main Point of Contact

4. Main point of contact for the family:

5. Preferred language of main point of contact:

6. Contact information of main point of contact:

Case Information & Deadlines

7. Type of case (i.e. Hardship Waiver; Cancellation of Removal; Asylum; VAWA; U-Visa; I-751, I-212, etc.) and focus of evaluation (if applicable):

8. Date(s) of any filing deadlines (if applicable):

9. Date you need the report submitted to your office:

Court Date Information (if applicable)

10. Date & time of court hearing:

11. Do you anticipate needing us to testify as an expert witness?

Law Firm

12. Attorney(s) point of contact (name, email, phone number):

13. Paralegal/Legal Assistant point of contact (name, email, phone number):

Other

14. Supporting Documents: Based on your discretion, if applicable and relevant to the case, please indicate if you plan to share any of the documents below.

(Upon submission, there are instructions on how to send us relevant documents)

a. RFE (Request for Further Evidence)

b. NOID (Notice of Intent to Deny)

c. Affidavit(s)/Personal Statement(s)

d. Police Report(s) (ex: U-Visa)

e. IEP(s) (Individualized Education Plan/Program)

f. Medical Records (only confirmation of diagnosis and list of medications)

g. Previous Psychological Evaluation(s)

15. Any other information not previously mentioned that we should be aware of:

Disclaimer:By providing my phone number to “Dalissy J Washington LLC” d/b/a “The Compassion Agents, I agree and acknowledge that “Dalissy J Washington LLC” may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled please see our privacy policy below: Privacy Policy: No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Referral Form

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