Pro Bono Referral Form

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Information About the Child

First Name *

Last Name *

Age *

Alien Registration Number *

Other names the child uses (including spelling variations/names on government documents)

Origin

Date of Birth *

Country of Origin *

First Language *

Please indicate additional languages in which child can communicate fluently

Health

Does the child have any special health needs or disabilities? Yes No

If you answered "YES" to the question above, please list and describe:

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Custody Information

LOPC Referral? * Yes No Is the child currently in ORR custody? * Yes No

If the child is currently in ORR custody, please provide the following

Facility Name

City

State

Zip Code

Expected Release

Date *

City *

State *

Long Term Foster Care

City

State

Zip Code

Please list any contact information for facility staff or other professionals
who have worked closely with this child

Please provide any available contact information for child's expected sponsor
upon release, including NAME, PHONE, and EMAIL

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Sponsor Information

If the child has been released, please provide the following

First Name

Last Name

Relationship with child

Home Phone

Work Phone

Cellular Phone

Email Address

Street Address

Apartment number / P.O. Box

City

State

Zip Code

Is the child living with parent? Mother Father Neither

Additional Contact Information

Child's Email

Additional Sponsor Phone

Additional Sponsor Email

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Information about person making the referral

First Name *

Last Name *

Relationship with child

If "Other", please describe below:

Email Address *

Referring Organization

Name of referring organization, if applicable

Address

City

State

Zip Code

Information about Prior Screenings

Has a legal screening been conducted for this child? Yes No

Who conducted the legal screening?

Please submit any prior intakes or screenings conducted to referrals@supportkind.org

Name

Phone Number

Email Address

Has the child received any assistance with his or her immigration matters in the released location? Yes No

If yes, please provide the name of the person who provided assistance:

If yes, please provide the name of the organization or law firm that provided assistance:

Please describe any other particular circumstances present in this case that may impact the child's legal representation: