Sample Intake Questionnaire



Sample Intake QuestionnairePersonal InformationPhone:__________________________________________Name:_________________________________________________________________FirstMiddle LastAddress: _____________________________________________________________________Date of Birth: _______________________Gender: ___________________________________Marital Status: _________________________________________________________________What is your current Immigration Status? ____________________________________________City and State you entered the US: _________________________________________________Date you entered the US: ________________________________________________________How did you enter the US? _______________________________________________________If Applicable, when did you get your lawful permanent residency? ________________________Do you have any pending applications with USCIS or Immigration Court? _________________If so, what applications? _________________________________________________________If married, what is the status of your spouse? ________________________________________Do you have children? ________________Where they born in the US? __________________Children’s name(s) and status: _____________________________________________________-6350026162000______________________________________________________________________________Complete this section ONLY if applicable:Do you have Pending Charges against youWhat are the charges? _________________________________________________________How many counts? _________Are all offenses on the same day? ____________________Criminal RecordDo you have prior arrests in the United States or any other countries? ______________________If yes, what was the basis of the arrest? _____________________________________________If yes, where did it happen? __________________ When did it happen? __________________Removal ProceedingsHave you ever been placed in deportation or removal proceedings? _______________________If yes, when and where? _________________________________________________________Assessment Questions:Have you ever been detained at a Port of Entry or U.S. Border Office? ___________If Yes: Where: __________________________ When: ________________________________Have you ever been refused entry into the U.S.? ______________If Yes: Where: ___________________________ When: ______________________________Have you ever been fingerprinted by an Immigration or Border Patrol Officer? __________If Yes: Where: ____________________________ When: _____________________________Have you ever appeared in front of an Immigration Judge? __________________________If Yes: Where: ____________________________ When: ______________________________Have you ever been denied any kind of visa? _____________________________________If Yes: Where: ____________________________ When: _____________________________Do you have any reason to fear returning to your home country? ______________________If Yes: Why:___________________________________________________________________Have you been involved in gangs, drug cartels or political conflict in the U.S. or your Country? ________If Yes: Where: _____________________________ When: ____________________________Have you been the victim of a crime while in the U.S.? _____________________________If Yes: Where: _____________________________ When: ____________________________Have you ever plead guilty or no contest to any crime in the U.S. or another country? _____If Yes: Where: _____________________________ When: _____________________________Have you ever been convicted of a crime involving drugs, weapons or fraud? ____________If Yes: Where: _____________________________ When: _____________________________Have you ever been arrested for a crime and no charges were filed or they were dismissed? ________If Yes: What Charges: ________________________ When: ___________________________Have you ever accepted public assistance such as “food stamp/EBT” Cash aide or Free Medical Services while in the U.S.? ____________________________________________If Yes: What Services : _________________________________________________________ Where: ______________________________ When: _________________________________Biographical InformationPlace of Birth: _____________________________Citizenship: ________________________Other Names Used: ____________________________________________________________City of Birth: _________________________________________________________________Ethnicity: ____ Hispanic____ Not HispanicRace: ___ White ___ African American ___ Asian ____ Other:____________Height: ___________ Weight: __________ Hair Color: ______________ Eye Color:________Parents:Father’s informationName: ___________________________________________________________________FirstMiddleLastPlace of Birth: ___________________________Date of Birth: ________________________City and Country of Residence: ____________________________________________________Mother’s informationName: ______________________________________________________________________FirstMiddleLastMaidenPlace of Birth: _____________________________Date of Birth: _______________________City and Country of Residence: ___________________________________________________CURRENT Spouse: ________________________Date of Birth: _______________________City and Country of Birth: _______________________________________________________Date of Marriage: _________________________Place of Marriage: ___________________FORMER Spouse: ________________________Date of Birth: _______________________City and Country of Birth: _______________________________________________________Date of Marriage: _________________________Place of Marriage:____________________Date Marriage Ended: _____________________Place Marriage Ended: ________________Residence – Last 5 years:____________________________________________________ to PRESENT Address Date FromDate to____________________________________________________ to ____________Address Date FromDate to_____________________________________________________ to ____________Address Date FromDate to____________________________________________________ to ____________Address Date FromDate to_____________________________________________________ to ____________Address Date FromDate to_____________________________________________________ to ____________Address Date FromDate toLast Address outside the United States of more than 1 year:____________________________________________________ to ____________Address Date FromDate toOccupations – Last 5 years__________________________________________________________ to PRESENT Employer NameAddressTitleDate FromDate to__________________________________________________________ to _____Employer NameAddressTitleDate FromDate to__________________________________________________________ to _____Employer NameAddressTitleDate FromDate to__________________________________________________________ to _____Employer NameAddressTitleDate FromDate to__________________________________________________________ to _____Employer NameAddressTitleDate FromDate toLast Employer outside the United States of more than 1 year:__________________________________________________________ to _____Employer NameAddressTitleDate FromDate toDependent and Spouse InformationCURRENT SpouseName: ____________________________________Date of Birth: _______________________City & Country of Birth: ________________________________________________________Current Address: ______________________________________________________________Immigration Status: _________________________SS#/A# ____________________________ChildName: ____________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________Current Address: _____________________________________________________________Immigration Status: ________________________SS#/A# ____________________________ChildName: ____________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________Current Address: _____________________________________________________________Immigration Status: ________________________SS#/A# ____________________________ChildName: ____________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________Current Address: _____________________________________________________________Immigration Status: ________________________SS#/A# ____________________________ChildName: ____________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________Current Address: _____________________________________________________________Immigration Status: ________________________SS#/A# ____________________________ ................
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