Asylum intake questions Form 2023

Asylum intake questions Form: What You Should Know

Have you ever been sentenced? YES NO. Have you ever been convicted? YES NO. Did you have mental health issues in the past? YES NO. Have you ever sought counseling in the past? YES NO. Have you ever been in prison, jail, or detention?  YES NO. Do you work or have a job? YES OR NO (If no, how often do you visit work or seek employment?) FACTORS TO CONSIDER (listed for each option in the document): Are you a U.S. citizen? YES NO Do you hold a green card? YES NO Are you a permanent resident? YES NO Have you ever applied for any type of relief or protection from U.S. authorities in the past? YES NO (not including parole, conditional release, withholding of removal, or refugee status) Is there any other information you would like to provide? (e.g. age, marital status, occupation, or educational level) YES OR NO (If yes, write the information below on a piece of paper and keep the forms in a secure place unless the form requires you to write your information down. This document may be photocopied on the day of service.) INFORMATION NOTES Are you known by another name, other than your maiden or native alphabetic spelling? If so, include the current name, as well as the maiden or native alphabetic spelling. (If yes, provide the last name as well and include the maiden or native alphabetic spelling.) Have you ever applied for any type of relief or protection from U.S. authorities in the past? YES NO Is there any other information you would like to provide? (e.g. age, marital status, occupation, or educational level) YES OR NO (If yes, write the information below on a piece of paper and keep the forms in a secure place unless the form requires you to write your information down. This document may be photocopied on the day of service.) I am in the process of applying for relief/protection from U.S. authorities and I do not wish my current name to be used for public disclosure if I apply. Are you familiar with the U.S. Citizenship and Immigration Services (USCIS) website?  Please visit or call . Please be advised that they are currently experiencing capacity issues.

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