Forensic Evaluation Request Form

Request for an in-person or virtual appointment
Will an in-person evaluation in MGH (55 Fruit St. Boston, MA) be necessary due to the sensitivity of the exam?

Issues with virtual appointments
If you anticipate that your client may have any issues accessing Zoom, please explain here. We will do our best to accommodate and provide tech support if necessary. 

If client is detained: please indicate if Jurislink or another service will be used.

Agency/Firm
If this is a pro bono case, please include your pro bono partner.

Example: WimerHail / PAIR

Please provide the name and e-mail of the supervising attorney:

Would your client prefer to have the evaluation conducted in English or another language?

We may be able to provide a certified medical interpreter, however, please be prepared to provide a qualified, non-family member interpreter if needed.

Client location (City & State)

Asylum applicants
Please check all that apply in regards to the basis for their asylum claim:

Please check all that apply to your client's case:

Registering for a Medical Record Number (MRN):
Please note that although there will be no medical documentation or charges associated with a visit to the MGH Asylum clinic, your client will need to be registered as patients to be seen.

Call the Massachusetts General Hospital Registration and Referral Center at 866-211-6588 to receive a medical record number (MRN) for your client. Please have the following information ready: client's name, address, date of birth, medical insurance, and emergency contact information. More information about the registration process can be found here.

Has your client registered for a medical record number at MGH?

Physical/Medical Evaluation:
Please specify all the physical findings (e.g. scars) your client experienced as a result of the trauma they suffered that you would like us to assess and document.

Psychological Evaluation:
Please describe the psychological symptoms your client experienced and/or continues to experience as a result of the trauma they suffered.

For example, symptoms clients may suffer from include but are not limited to the following:
- Depression: depressed mood, loss of interest, sleep and appetite changes, decreased energy and concentration, self harm and suicidality
- Post-traumatic syndromes: intrusive thoughts (eg nightmares, flashbacks, frequent disturbing memories), avoidance (eg repression, inability to discuss trauma), hypervigilance (eg easy startle, panic attacks, irritability), and negative cognitions (eg self-blame, difficulty recalling events)

1-Year Deadline
Are you seeking an evaluation to help explain why a client was unable to meet the 1-year deadline to file? If so, please describe why you believe this individual was unable to file for asylum within a year of arriving in the United States.

Would your client prefer a male or female evaluator?

Note: Requesting a specific gender may lead to some delays in placement.

When is the individual/merits hearing date or asylum interview date?

If not yet scheduled, please note this in the case details section.

Who is the Immigration Judge (IJ)?

By when do you need the written affidavit to be completed?

We generally require a minimum of 8 weeks to complete an evaluation and a medical affidavit. If this is a flexible or urgent deadline, please note it in the next section.

Declaration

Please upload your client's declaration in support of their asylum/humanitarian relief claim. This does not have to be a final draft. Without a declaration, we cannot place a case.

Does your client have an active Primary Care Physician (PCP)?

Has your client received medical care in the US for injuries or mental health issues related to the reported persecution?
If yes, please provide the physician's name.

Please upload any available medical records related to the reported persecution.