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Referral Source:
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Name of Organization:
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If associated with an office or organization, please provide their name.
Contact Person Name:
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First
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Contact Person Phone:
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Contact Person Email:
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Immigration Assistance Being Requested
Child Under 21
Does this request for immigration assistance involve a child or young adult under the age of 21?
Yes
No
Active Child Welfare Case
Does this request for immigration assistance involve a child or young adult with an active child welfare case?
Yes
No
While all referrals will be reviewed, Child Advocates legal team cannot accept cases unless the child is involved with the child welfare system.
County of Child Welfare Case:
Adams County
Allen County
Bartholomew County
Benton County
Blackford County
Boone County
Brown County
Carroll County
Cass County
Clark County
Clay County
Clinton County
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Henry County
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Jay County
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Ohio County
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Posey County
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Putnam County
Randolph County
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Scott County
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Spencer County
St. Joseph County
Starke County
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Union County
Vanderburgh County
Vermillion County
Vigo County
Wabash County
Warren County
Warrick County
Washington County
Wayne County
Wells County
White County
Whitley County
DCS Family Case Manager Name:
First
Last
Child's Legal Name:
First
Last
Preferred / Chosen Name
Pronouns
Child's Age:
Select Child's Age
< 1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old
20 years old
21 years old
Child's Preferred Language:
CHINS Cause Number:
(if known)
Pending Immigration Court Date or Removal:
MM slash DD slash YYYY
Immigration Status:
(select one)
Permanent Resident (Green Card Holder)
Undocumented
Refugee
Citizen
Unknown
Summary of Immigration Need/Request:
This information is being provided only for the purpose of determining the ability of Child Advocates’ legal team to assist the youth with immigration matters. Information provided will be kept confidential and not disclosed beyond the purposes of this referral. Once a case is accepted, additional identifying information will be requested.
Upload your birth certificate:
Accepted file types: jpg, png, pdf, Max. file size: 300 MB.
Upload identification documents:
Accepted file types: jpg, png, pdf, Max. file size: 300 MB.
Upload immigration documents:
Accepted file types: jpg, png, pdf, Max. file size: 300 MB.
Name
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