Online Immigration Intake Form

Attorney Name*

First Last

Attorney Email*

County where client is charged*

Public defender/assigned counsel?*

Yes
No

(Are you representing an indigent client in this case?)

Are you a WDA member?*

Yes
No

(If your agency is an organizational member, you are a member. Membership is not required for assistance.)

Today's Date*

Defendant Identifier

(Not Required)

Need Response By Date and Time*

If urgent and response needed within 48 hours please mark URGENT here

Defendant's DOB*

Defendant's Place of Birth*

First Date of Entry into the U.S.*

Last Date of Entry into the U.S.*

It is important for us to know whether client has entered the U.S. multiple times.

Immigration Status*

LPR - Lawful Permanent Resident (greencard) *indicate below since when, if different than date of entry
Refugee (approved before arrival in U.S.)
Asylee (granted after arrival in U.S.) *indicate date of grant below
Undocumented *indicate whether entered without inspection or with visa that is now expired
DACA
Previously Deported
Unknown *NOTE: WDA’s Immigration Project staff cannot provide you with accurate advice about the immigration consequences facing your client without knowing client’s specific immigration status. Please communicate with your client to determine status before submitting this form. If your client is unclear about her/his status, please provide details of what is known in comments below. Also, please see our Determining Immigration Status Resource for helpful questions to ask your client.
Other * indicate details below

If LPR or refugee, please write date that appears on their card (e.g. "LPR since: ___") in the comments box below. If undocumented, please write in when defendant entered the country. If previously deported, please write in whether defendant was deported by ICE or an immigration judge.

Comments on Immigration Status*

Indicate when client obtained lawful status or came to the US or was previously deported.

Defendant is...*

in custody
out of custody

ICE Detainer*

Yes
No

If yes, please explain

Current Charges*

(include what court your client is charged in; please indicate if DV or drug-related, or if there are any gang allegations)

Past Criminal History (anywhere)*

Include offense, date of conviction and sentence (including suspended time) for each conviction, in any state or country. Include arrests, deferred adjudications, deferred sentences, juvenile history, or other resolutions. Be sure to indicate if DV or drug-related, or if there were any gang allegations or findings.

Plea Offers for Current Charge*

Defendant's Goals Re: Immigration Consequences*

Avoid conviction that triggers deportation
Preserve eligibility to obtain future immigration benefits (e.g. LPR status or citizenship)
Preserve ability to ask immigration judge to get/keep lawful status and stay in U.S.
Get out of jail ASAP
Immigration consequences, including deportation, are not a priority

Spouse/Partner is...*

Mother is...*

If USC, since when?

Father is...*

If USC, since when?

Are/were any grandparents USC(s)?*

Children: list age and immigration status for each

If none, please write "no children" in the box below.

Kids are...*

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Phone

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Immigration Intake Form

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