Non-US Citizen Worksheet

Department of Family and Protective Services (DFPS) Form 2203 Revised Oct 2013

NON-US CITIZEN WORKSHEET APS

Purpose: To identify any client who may have a path to obtaining permanent resident status or entitlement to refugee status. Instructions: Please complete all requested information as thoroughly as possible and attach all documents. Submit: Please return this form to the APS Policy Team using the In-Home Mailbox.

1. Client’s Name and IMPACT ID:

2. Region:

3. APS Specialist’s Name & Phone #

4. Supervisor’s Name & phone #

5. Date form submitted to State Office:

AGE/COUNTRY OF ORIGIN

Date of birth or approximate age:

Place of birth?

How long did the client reside there?

Attach a copy of a birth certificate, baptismal certificate, etc.

IMMIGRATION ISSUES

Has the client ever been deported by INS? If yes, when:

What year did the client immigrate to the U.S.?

How long has the client resided in the U.S.?

Was residence continuous?

of 4 Department of Family and Protective Services (DFPS) Form 2203 Revised Oct 2013

Attach any immigration documents. List any immigration numbers available.

FAMILY Does the client have any immediate family members who are U.S. Citizens? If yes, list name and relationships:

Have family members listed above been contacted by APS?

CRIMINAL HISTORY Has the client ever been convicted of a crime? If yes, what was the crime and when did it occur?

LANGUAGE Does the client speak English?

If the client does not speak English, what language(s) does client speak?

CONTACT WITH APS Who referred the client to APS?

What is the immediate reason for referral to APS?

What is the APS service plan for this client?

CLIENT’S ABILITIES AND NEEDS List the client’s major mental and/or physical disabilities.

Does the client require assistance with ADL’s?

What is the client’s medical condition?

Does the client have a physician?

Does the client require medications? If yes, list medications and medical problems.

Does the client have all needed medications?

How are medications purchased?

Is the client at risk for HIV/AIDS?

Has the client been tested for HIV/AIDS? If yes, what was the result of the HIV/AIDS test?

Does the client have mental capacity to make decisions for him/herself? If no, what incapacitates client?

Has the client had a professional evaluation of his/her capacity? If yes, by whom and when?

Does the client have mental or emotional problems that make him/her a danger to self or others? If yes, describe.

Is the client involved with Facilities? If yes, describe services received.

What is the client’s current living situation? Can it continue?

Does the client have any type of support system? If yes, who and what support is offered?

Does the client need placement in a facility? If yes, what type?

MISCELLANEOUS If the client is a citizen of Mexico, has the client's family/caseworker contacted DIF regarding the possibility of placing client in Mexico? If yes, what were the results?

Name country of origin, if other than Mexico

List every identifiable hardship (e.g., social, financial, medical, emotional) if the client is returned to his/her country of origin.

List any individual or entity (e.g., family, friends, church, community organization) that might be willing to write a letter of support for the client to remain in the U.S.

QUESTIONS List specific questions or needs regarding this referral. This will aid State Office Policy Team and Legal in understanding and responding directly to the nature of the request.