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QDEP Request for Social Services Form

(form is HIPAA compliant)

Date of Referral

Referred by whom?

Detainee Information

Name

Date of Birth (mm/dd/yyyy)

A Number

Nationality

Gender Identity

English Proficiency (please describe)

Phone Number

Attorney Information

Attorney Name

Attorney Phone Number

Attorney Email Address

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Email Address

Current Immigration Status

Current Case Status

Any criminal convictions? Please describe.

Details of detainment

Dates detained (mm/dd/yyyy-mm/dd/yyyy)

Location(s)

Referral Reason

Parole assistance for asylum seeker (ATD)

Release assistance, special circumstances (ATD)

Post release planning (SS)

Deportation (SS)

Please describe any ongoing health and/or mental health conditions, as well as treatment thus far.

Please use this section to describe pertinent information about the client's HIV status, sexual orientation, or other important case information.

Following submission of this form, please email most recent psychiatric assessment, biopsychosocial assessment and TB test to jamila@qdep.org.

Permission to release information

I authorize [attorney or other contact indicated above] to release any and all information about my case to a network of social service providers. A social service provider will contact me if they can assist with my case. I am not obligated to meet with any social service providers.
[Attorney or other contact indicated above] are not responsible for any assistance provided by these
people or organizations.

Yo autorizo a [attorney or other contact indicated above] para dar cualquier información sobre mi caso a una red de proveedores de servicios sociales. Un proveedor de servicios sociales me contactará sí el/ella está dispuesto/a a ayudar con mi caso. No estoy obligado a reunirme con ningún proveedor de servicios sociales. [attorney or other contact indicated above] no son responsables por la asistencia proveída por estas personas u organizaciones.

Client Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date