New Client Intake | Cothias Law

Contact Information

Today's date

Referred by

Full name

Cell phone

Other phone

Address

Date of birth

Email

Nationality

Place of birth

Maiden name or other names used

Other languages spoken (besides preferred)

Preferred language for communication

Mailing address, if different from above

Current marital status

Place of marriage (if applicable)

Date of divorce (if applicable)

Ethnicity

Nationality at birth (if different from current)

Race (optional, check all that apply)

White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Pacific Islander

Religion

Immigration History

When did you first enter the U.S.?

When was the last time you entered?

How did you enter the last time?

List all entries to and exits from the U.S.

Give dates, and note whether you went through an immigration inspection. Please have copies of any visas or I-94s ready for your consultation.

Entry	Exit	Inspected?	Status/visa on entry	Authorized stay expired

When did you last leave your home country?

Place of last entry to the U.S.

I-94 number, if applicable

Passport number

Passport expiration date

Country that issued passport

Current immigration status

Date current status expires

What problems have brought you here? What do you hope we can help with?

Parents' & Siblings' Information

Mother's full name

Place of birth

Current location (or deceased)

Father's full name

Place of birth

Current location (or deceased)

Sibling name	Place of birth	Current location (or deceased)

Address History

Please list all places you've resided for the past five years.

Address	Resided from	Resided to

Most recent address outside the U.S. (if different from above)

Immigration & Court History

Have you ever been ordered removed or deported from the U.S.?

Have you ever been in immigration court?

Have you ever been stopped by immigration officials?

If yes to any of the above, please describe

Have you ever applied for any immigration benefit?

Examples: permanent residency, asylum, amnesty, TPS, cancellation, suspension, Family Unity, DACA, visa petition, U visa, T visa, SIJS, or any other benefit.

If so, when and what type of paperwork?

What was the result?

Has any paperwork been filed on your behalf? (e.g., a visa petition by family)

Family

Were your parent(s) or grandparents U.S. citizens?

Are you married?

When and where?

Do you have children?

Do you have any other family members in the U.S.?

Employment in the U.S.

Dates and types of employment, name and address of employer.

Employer name	Employer address	Type of employment	Period of employment	Work authorized?

Memberships

Organizations, churches, associations, or unions you've belonged to. This can matter for certain types of cases, including asylum.

Organization	Location	Nature of group	Member from	Member until

Education History

School name	Type of school	Address	From	To

Background & Safety Screening

These questions help us identify protections you may be entitled to, such as asylum, U visas, T visas, or VAWA relief.

Have you ever had trouble with the police or been arrested in the U.S.? If so, when, for what, and what sentence did you receive?

Do you have any reason to fear going back to your country? Who do you fear, and why?

Have you ever been a victim of domestic abuse by a spouse, parent, or child?

Have you ever been threatened or harmed by a spouse, parent, or child?

If so, did they have U.S. citizenship or lawful permanent residency?

Please describe

Have you ever been the victim of a crime? If so, what crime?

If so, did you report it to police or help with the investigation/prosecution?

Did anyone recruit you in your home country to work in the U.S.?

Did you feel forced or tricked into working?

Were you required to work without pay, or less pay than allowed/expected?

Have you been abandoned, abused, or neglected by a parent? Are you currently under the jurisdiction of a juvenile court (dependency, delinquency, or probate guardianship)?

Child's name	DOB & place of birth	Nationality	Immigration status	In U.S. now?	If not, current location

Name	Relation	Immigration status	In U.S. now?