Immigration Evaluation Prescreening Form

Thank you for your interest in an Immigration Psychological Evaluation with Peace-Filled Mental Health Counseling Services, LLC.

Please complete this brief form so we can determine the type of evaluation you need and the next steps.

First Name

Last Name

Phone *

Email *

Date of birth

Preferred Language

If your preferred language was not listed, please specify:

Do you need an Interpreter?

Who referred you?

Do you have an attorney representing you in your immigration case?

If yes, please answer the following questions:

Attorney’s Full Name

Law Firm Name

Attorney’s Email

Attorney’s Phone Number

Would you like us to send your completed evaluation directly to your attorney?

What type of immigration case do you have?

If your type of immigration case was not listed, please specify:

When does this evaluation need to be completed?

Briefly describe why you are seeking an immigration evaluation at this time.

Country of origin

How long have you lived in the U.S.?

Current immigration status:

Are you currently receiving therapy, counseling, or psychiatric treatment?

Do you have any physical or mental health diagnoses or concerns you’d like us to know about?

Briefly describe any significant past experiences relevant to your case (e.g., trauma, abuse, separation, threats)?

Are you comfortable completing the evaluation via telehealth (video)?

Are you able to make payment prior to the evaluation session?

How did you hear about our services?

If other, please specify:

After you submit this form:

1. Our office will review your information within 1–2 business days.

2. If appropriate, we will contact you to schedule a consultation or send intake and payment details.

3. Evaluations usually require 2-3 sessions, and the report is typically completed within 7–14 days.

By submitting this form, I understand that this prescreening does not establish a therapeutic relationship or guarantee service.