Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">SUBMITTING A REQUEST Once we have received your referral, a staff member will follow up with you regarding any questions or concerns. If you do not hear back from an Evaluation Network staff member regarding your referral within 5-7 business days, please call 206.806.1061 to follow up. In supplement to this referral form, the following information is REQUIRED before we can review your request: 1) A full draft of your client’s declaration 2) Any additional information about criminal history, substance abuse or illegal substance use, or any other relevant information regarding the asylum claim </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">LIMITATIONS The Evaluation Network prioritizes evaluation requests for applicants who are represented pro-bono in their immigration case(s) with set deadlines (ICH or USCIS Interview). Please be advised that during this pandemic period of reduced volunteer capacity and high demand, we may be unable to consider requests for low-bono or paying clients. If you would like to receive more information about alternative, reduced-cost psychological evaluation services for a low-bono or paying client, or to check in with our team about capacity for low-bono/paying client referrals, please contact us at evalnetteam@lcsnw.org. The network also prioritizes referrals for Survivors of Torture and those who have a connection to the city of Seattle (live, work, or go to school in the city limits). At this time we are not able to prioritize T- and U-Visa applicants.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">EVALUATION TIMELINES Note: A referral is not a guarantee that an evaluation will occur. After receipt and approval, a staff member will try to schedule the requested assessment(s) with available and appropriate volunteer evaluator(s). Due to the limited capacity of NWHHR staff and volunteers, please allow at least 8 weeks to process, schedule, conduct, and finalize an evaluation. Requests for expedited evaluations may be considered if a volunteer has an unfilled opening. Exact wait and processing times may vary, please contact at evalnetteam@lcsnw.org or 206.806.1061 for clarification on current wait times. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">INTERPRETATION Note: It is first and foremost the referring law firm's responsibility to provide independent interpretation for all evaluations (interpreter cannot be a family member, close friend of the client or a law firm staff member). If you do not have any such resources or would require the applicant to pay for the interpretation, the Evaluation Network may be able to arrange an interpreter. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">DRAFT & FEEDBACK EXPECTATIONS Note: Completion of an evaluation appointment does not guarantee that the volunteer will draft an affidavit. Volunteers reserve the right to decline or retract their affidavits at any point. In an effort to maintain the independence and integrity of the evaluations, we ask that no sentences or information be directly added into the affidavit text by anyone other than the evaluator. This being said, conscientious feedback is encouraged. We ask, however, that all questions and recommendations be clearly indicated with appropriate context given so that the volunteer evaluators can adequately assess the suggestions. Volunteer evaluators have the right to accept or decline any recommendations in accordance with their clinical and ethical judgement. After the assessment, volunteer evaluators typically need at least 10-12 business days to draft their affidavit. We ask that you also respond with any feedback, edit suggestions, etc. within 10 business days. This will help ensure that the evaluators are able to respond to questions, sign/finalize documents, etc. within a timely manner. Due to the volunteer's limited availability, we are unable to accommodate last minute or delayed edits or signature requests.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">COMMUNICATION WITH VOLUNTEERS In an effort to protect the independence and objectivity of our volunteers, we ask that attorneys not directly contact any NWHHR network members without their expressed permission. This includes, but is not limited to: requesting an evaluation, providing case information, or providing feedback on an affidavit. We ask that all requests, questions, and feedback be submitted through the NWHHR evaluation coordinator or supporting staff. Please note: Our volunteers kindly ask that they not be contacted regarding other evaluation referrals or requests, including requests for paid evaluations or other non-asylum evaluations. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">HIPAA & SECURITY The Evaluation Network uses Virtru, a free email encryption software, when emailing documents and protected health information. Virtru is a free service and is available for public use. For more information, see https://www.virtru.com/secure-email/. You are not required to use Virtu, but we do ask you to send documents that contain private client information via Virtru or another HIPAA compliant system. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"><i class="fa fa-pencil"></i><label class="er_fld_label required">I have read and agreed to the above policies and proceedures</label><div class="cst_signaturepad"></div><input name="CST_56" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Applicant Information and Demographics</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Name_First"><i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_28" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Name_Middle"><i class="fa fa-font"></i><label class="er_fld_label">Middle Name</label><input name="CST_32" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Name_Last"><i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_34" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"><i class="fa fa-font"></i><label class="er_fld_label">Preferred Name (Optional)</label><input name="CST_36" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col1 er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Gender"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Gender Identity</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" value="Male (Cis)">Male (Cis)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" value="Female (Cis)">Female (Cis)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" value="Trans Male (He/Him)">Trans Male (He/Him)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" value="Trans Female (She/Her)">Trans Female (She/Her)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_38" value="Non-Binary ">Non-Binary </label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_38" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_38_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;" map_to="CC_DOB"><i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_35" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Religion"><i class="fa fa-font"></i><label class="er_fld_label">Religion (Optional)</label><input name="CST_41" type="text" value="Unknown"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="Country_UNID"><i class="fa fa-font"></i><label class="er_fld_label required">Country of Origin</label><input name="CST_39" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="Nothing"><i class="fa fa-font"></i><label class="er_fld_label">Ethnicity (Optional)</label><input name="CST_40" type="text" value="Unknown"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_Language"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Language</label><select name="CST_29" class="er_fld_required"><option value="Abé">Abé</option><option value="Afrikaans">Afrikaans</option><option value="Agni">Agni</option><option value="Amharic">Amharic</option><option value="Arabic">Arabic</option><option value="Attié">Attié</option><option value="Baoulé">Baoulé</option><option value="Bété">Bété</option><option value="Bhote-Sherpa">Bhote-Sherpa</option><option value="Bhutanese">Bhutanese</option><option value="Bosnian ">Bosnian </option><option value="Burmese">Burmese</option><option value="Cantonese">Cantonese</option><option value="Chepang">Chepang</option><option value="Chin Lai">Chin Lai</option><option value="Chin Matu">Chin Matu</option><option value="Chin Zotung">Chin Zotung</option><option value="Creole">Creole</option><option value="Croatian">Croatian</option><option value="Cyrillic">Cyrillic</option><option value="Danuwar">Danuwar</option><option value="Darai">Darai</option><option value="Dari">Dari</option><option value="Dhimal">Dhimal</option><option value="Dinka">Dinka</option><option value="Dioula">Dioula</option><option value="English">English</option><option value="Ewe">Ewe</option><option value="Falaam">Falaam</option><option value="Farsi ">Farsi </option><option value="French">French</option><option value="Guéré">Guéré</option><option value="Gurung">Gurung</option><option value="Hakka">Hakka</option><option value="Hindi">Hindi</option><option value="Italian">Italian</option><option value="Jirel">Jirel</option><option value="Kanjobal (Qanjobal)">Kanjobal (Qanjobal)</option><option value="Karen">Karen</option><option value="Kiche (Quiche)">Kiche (Quiche)</option><option value="Kikongo (Kituba)">Kikongo (Kituba)</option><option value="Kinyarwanda">Kinyarwanda</option><option value="Kirundi">Kirundi</option><option value="Kiswahili">Kiswahili</option><option value="Krio">Krio</option><option value="Kron (Liberian) Arkanese">Kron (Liberian) Arkanese</option><option value="Kumhal">Kumhal</option><option value="Kurdish">Kurdish</option><option value="Limbu">Limbu</option><option value="Lingala">Lingala</option><option value="Lobi">Lobi</option><option value="Maam (please specify region below)">Maam (please specify region below)</option><option value="Magar">Magar</option><option value="Mahou">Mahou</option><option value="Majhi">Majhi</option><option value="Mandarin">Mandarin</option><option value="Mara">Mara</option><option value="Newar">Newar</option><option value="Nuer">Nuer</option><option value="Oromo">Oromo</option><option value="Pashto">Pashto</option><option value="Portuguese">Portuguese</option><option value="Punjabi">Punjabi</option><option value="Quechan">Quechan</option><option value="Rai-Kirant">Rai-Kirant</option><option value="Rajbansi">Rajbansi</option><option value="Raji">Raji</option><option value="Rohingya">Rohingya</option><option value="Sénoufo">Sénoufo</option><option value="Serbian Latin">Serbian Latin</option><option value="Sgaw Karen">Sgaw Karen</option><option value="Sinhala">Sinhala</option><option value="Somali">Somali</option><option value="Soninke">Soninke</option><option value="Spanish">Spanish</option><option value="Swahili">Swahili</option><option value="Swazi">Swazi</option><option value="Tamang">Tamang</option><option value="Tamil">Tamil</option><option value="Telugu">Telugu</option><option value="Thai">Thai</option><option value="Thakali">Thakali</option><option value="Thami">Thami</option><option value="Tharu">Tharu</option><option value="Tidim">Tidim</option><option value="Tigrinya/Tigray">Tigrinya/Tigray</option><option value="Tshiluba">Tshiluba</option><option value="Turkish">Turkish</option><option value="Urdu">Urdu</option><option value="Wobé">Wobé</option><option value="Yacouba">Yacouba</option><option value="Zulu">Zulu</option><option value="Other" selected="">Other</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Other Languages</label><input name="CST_30" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_Phone_Home"><i class="fa fa-font"></i><label class="er_fld_label">Applicant Phone #</label><input name="CST_46" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_EMail"><i class="fa fa-font"></i><label class="er_fld_label">Applicant Email</label><input name="CST_47" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Additional Contact Information</label><input name="CST_54" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_Address_City"><i class="fa fa-font"></i><label class="er_fld_label required">Applicant's City of Residence</label><input name="CST_26" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 50%;"><i class="fa fa-hashtag"></i><label class="er_fld_label"> A#</label><input name="CST_49" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">*ELDN #</label><input name="CST_20" type="text" value="N//A"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CustomField_Value_7"><i class="fa fa-font"></i><label class="er_fld_label">**NWIRP Server#</label><input name="CST_19" type="text" value="N/A"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="CustomField_Value_2"><i class="fa fa-font"></i><label class="er_fld_label">***SOT#</label><input name="CST_21" type="text" value="Not Yet Assigned"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 25%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint">*Colectiva, WACC, NWIRP, ACRS, KIND, Entre Hermanos Only </div></li><li class="er_fld_type_content" draggable="false" style="width: 25%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint">**NWIRP Only</div></li><li class="er_fld_type_content" draggable="false" style="width: 25%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint">***HMC, RNW & NWIRP Only </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_FamSize"><i class="fa fa-font"></i><label class="er_fld_label">Household Size in the US (Optional)</label><input name="CST_42" type="text" value="Unknown"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_MaritalStatus"><i class="fa fa-font"></i><label class="er_fld_label">Marital Status (Optional)</label><input name="CST_55" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CustomField_Value_8"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Housing Status</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Homeless - Couch Surfing">Homeless - Couch Surfing</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Homeless - Shelter">Homeless - Shelter</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Homeless - Living outside">Homeless - Living outside</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Living with Host Family">Living with Host Family</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Living with Family or Friends ">Living with Family or Friends </label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Renting an An Apartment (on own)">Renting an An Apartment (on own)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Renting/Subletting Apartment (with others)">Renting/Subletting Apartment (with others)</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Owns house or condo">Owns house or condo</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_45" value="Unknown">Unknown</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false" map_to="CC_Employment"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Employment Status</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_43" value="Employed - EAD">Employed - EAD</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_43" value="Employed- No EAD">Employed- No EAD</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_43" value="Unemployed -EAD">Unemployed -EAD</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_43" value="Unemployed - No EAD">Unemployed - No EAD</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_43" value="Detained">Detained</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_43" value="Unknown">Unknown</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_43" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_43_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Referring Agency Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringWorker_Ref"><i class="fa fa-font"></i><label class="er_fld_label required">Your Name </label><input name="CST_17" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferralSource_Ref"><i class="fa fa-font"></i><label class="er_fld_label required">Referring Agency/LawFirm</label><input name="CST_18" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label required">Mailing Address</label><input name="CST_50" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label required">Direct Phone Number</label><input name="CST_53" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label required">Fax</label><input name="CST_51" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_52" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Services Requested</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Client Type</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Pro-Bono">Pro-Bono</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Low-Bono">Low-Bono</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_16" value="Franco">Franco</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_16" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_16_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CC_Category_Ref"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Type of Evaluations Requested</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_22" value="Medical">Medical</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_22" value="Psychological">Psychological</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_22" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_22_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Case Type</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Affirmative Asylum">Affirmative Asylum</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Defensive Asylum">Defensive Asylum</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Derivative Applicant">Derivative Applicant</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="VAWA">VAWA</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="SIJ">SIJ</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="U-Visa">U-Visa</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="T-Visa">T-Visa</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Withholding of Removal">Withholding of Removal</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_15" value="Convention Against Torture">Convention Against Torture</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_15" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_15_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Special Considerations</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="N/A">N/A</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Detained Applicant">Detained Applicant</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Interpretation Support Needed">Interpretation Support Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Rare Language">Rare Language</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Testimony Likely Needed">Testimony Likely Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Expedited Case">Expedited Case</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Complex/Unusual Case">Complex/Unusual Case</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Female Evaluator Preferred">Female Evaluator Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Male Evaluator Preferred">Male Evaluator Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Geriatric Specialist Needed">Geriatric Specialist Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Pediatric Specialist Needed">Pediatric Specialist Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Neurological Specialist Needed">Neurological Specialist Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Invasive Medical Eval at NWDC">Invasive Medical Eval at NWDC</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_13" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_13_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Case Status and Request Timeline Confirm the I-589 has been submitted. What are there the deadlines: internal, ICH or USCIS Interview date?</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;"><i class="fa fa-paragraph"></i><label class="er_fld_label required"></label><textarea name="CST_7" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Case Summary e.g. Asylum, based on PSG: The applicant was arrested and tortured because of their imputed sexual identity Example: [applicant/applicant initials] is a [age range] individual seeking asylum from [region/country] based on [race, religion, nationality, membership in a particular social group or political opinion]. *Having a case summary is critical for the matching process. Having accurate information in this section helps our team match cases with the most capable evaluator.*</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"><i class="fa fa-paragraph"></i><label class="er_fld_label"></label><textarea name="CST_90" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Specific Areas to Evaluate e.g. Psych: please assess for any memory problems, past or ongoing mental health symptoms or disorders associated with being tortured by the police e.g. Med: Applicant has scars on his hand, foot, and stomach. Applicant reports experiencing ongoing migraine headaches since being tortured by the police e.g. Neuro: Applicant may have been hit in the head while being tortured. Applicant's thought process is really hard to follow and his memory/narratives are inconsistent and disorganized. Please assess for any cognitive impairment or traumatic brain injury</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;"><i class="fa fa-paragraph"></i><label class="er_fld_label required"></label><textarea name="CST_8" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">History of Substance Use or Criminal Charges Please Note: We are unable to serve any applicant with a record of violent criminal offenses.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"><i class="fa fa-paragraph"></i><label class="er_fld_label"></label><textarea name="CST_9" style="width:100%;">N/A</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Case Deadlines (If Applicable)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 25%;"><i class="fa fa-calendar"></i><label class="er_fld_label">Filing Deadline</label><input class="cst_datepicker" name="CST_14" type="text" value=""></li><li class="er_fld_type_date" draggable="false" style="width: 25%;"><i class="fa fa-calendar"></i><label class="er_fld_label">ICH Date</label><input class="cst_datepicker" name="CST_88" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">ICH Location</label><input name="CST_4" type="text" value="N/A"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Testimony Requested?</label><select name="CST_3" class=""><option value="N/A" selected="">N/A</option><option value="Med Only">Med Only</option><option value="Psych Only">Psych Only</option><option value="Both Psych and Med">Both Psych and Med</option><option value="Unknown">Unknown</option></select></li><li class="er_fld_type_time" draggable="false" style="width: 25%;"><i class="fa fa-clock-o"></i><label class="er_fld_label">Time</label><input class="cst_timepicker" name="CST_2" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"><i class="fa fa-font"></i><label class="er_fld_label">Judge</label><input name="CST_5" type="text" value="N/A or Unknown"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Scheduling Logistics</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Scheduling Preferences</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Mondays ">Mondays </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Tuesdays">Tuesdays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Wednesdays">Wednesdays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Thursdays">Thursdays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Fridays">Fridays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Saturdays">Saturdays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Sundays">Sundays</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Advance Notice Needed">Advance Notice Needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Detained">Detained</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Afternoons Preferred">Afternoons Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Mornings Preferred">Mornings Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Evenings Preferred">Evenings Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Weekends Preferred">Weekends Preferred</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Weekdays Preferred">Weekdays Preferred</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_12" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_12_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Communication Preferences</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Call Attorney">Please Call Attorney</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Email Attorney">Please Email Attorney</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Text Attorney ">Please Text Attorney </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Call Applicant - With Phone Interpreter">Please Call Applicant - With Phone Interpreter</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Call Applicant ">Please Call Applicant </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Email Applicant">Please Email Applicant</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Please Text Applicant">Please Text Applicant</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_33" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_33_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Transportation</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="N/A - Applicant is Detained">N/A - Applicant is Detained</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Applicant Drives">Applicant Drives</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Applicant Takes a Bus">Applicant Takes a Bus</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Applicant Takes a Taxi/Uber/Lyft">Applicant Takes a Taxi/Uber/Lyft</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Applicant Will be Driven by Family or Friends">Applicant Will be Driven by Family or Friends</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_27" value="Attorney/Law firm will Transport Applicant">Attorney/Law firm will Transport Applicant</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_27" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_27_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="CustomField_Value_3"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Interpretation Needed?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_31" value="N/A- Fluent English Speaker">N/A- Fluent English Speaker</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_31" value="Yes- Attorney will Coordinate">Yes- Attorney will Coordinate</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_31" value="Yes- Please Follow Up">Yes- Please Follow Up</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_31" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_31_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>ATTACHED DOCUMENTS</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Please email the following *required* documents to evalnetteam@lcsnw.org. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_selected" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">*Required Documents</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_57" value="*Full Draft of Declaration">*Full Draft of Declaration</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_57" value="*Release of Information">*Release of Information</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_57" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_57_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Optional Additional Documents</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_58" value="Medical Records">Medical Records</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_58" value="I-589 or other court documents">I-589 or other court documents</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_58" value="Police Reports">Police Reports</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_58" value="Previous Assessments">Previous Assessments</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_58" value="Other:">Other:<input class="cst_Other" name="CST_58_Other" type="text"></label></li></ul>
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