<p>Department of Family and Protective Services (DFPS) Form 2203 Revised Oct 2013</p><p>NON-US CITIZEN WORKSHEET APS</p><p>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.</p><p>1. Client’s Name and IMPACT ID: </p><p>2. Region: </p><p>3. APS Specialist’s Name & Phone # </p><p>4. Supervisor’s Name & phone # </p><p>5. Date form submitted to State Office: </p><p>AGE/COUNTRY OF ORIGIN</p><p>Date of birth or approximate age: </p><p>Place of birth? </p><p>How long did the client reside there? </p><p>Attach a copy of a birth certificate, baptismal certificate, etc.</p><p>IMMIGRATION ISSUES</p><p>Has the client ever been deported by INS? If yes, when: </p><p>What year did the client immigrate to the U.S.? </p><p>How long has the client resided in the U.S.? </p><p>Was residence continuous? </p><p>Page 1 of 4 Department of Family and Protective Services (DFPS) Form 2203 Revised Oct 2013</p><p>Attach any immigration documents. List any immigration numbers available.</p><p>FAMILY Does the client have any immediate family members who are U.S. Citizens? If yes, list name and relationships: </p><p>Have family members listed above been contacted by APS? </p><p>CRIMINAL HISTORY Has the client ever been convicted of a crime? If yes, what was the crime and when did it occur? </p><p>LANGUAGE Does the client speak English? </p><p>If the client does not speak English, what language(s) does client speak? </p><p>CONTACT WITH APS Who referred the client to APS? </p><p>What is the immediate reason for referral to APS? </p><p>What is the APS service plan for this client? </p><p>CLIENT’S ABILITIES AND NEEDS List the client’s major mental and/or physical disabilities. </p><p>Does the client require assistance with ADL’s? </p><p>What is the client’s medical condition? </p><p>Does the client have a physician? </p><p>Does the client require medications? If yes, list medications and medical problems. </p><p>Page 2 of 4 Department of Family and Protective Services (DFPS) Form 2203 Revised Oct 2013</p><p>Does the client have all needed medications? </p><p>How are medications purchased? </p><p>Is the client at risk for HIV/AIDS? </p><p>Has the client been tested for HIV/AIDS? If yes, what was the result of the HIV/AIDS test? </p><p>Does the client have mental capacity to make decisions for him/herself? If no, what incapacitates client? </p><p>Has the client had a professional evaluation of his/her capacity? If yes, by whom and when? </p><p>Does the client have mental or emotional problems that make him/her a danger to self or others? If yes, describe. </p><p>Is the client involved with Facilities? If yes, describe services received. </p><p>What is the client’s current living situation? Can it continue? </p><p>Does the client have any type of support system? If yes, who and what support is offered? </p><p>Does the client need placement in a facility? If yes, what type? </p><p>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? </p><p>Name country of origin, if other than Mexico </p><p>List every identifiable hardship (e.g., social, financial, medical, emotional) if the client is returned to his/her country of origin. </p><p>Page 3 of 4 Department of Family and Protective Services (DFPS) Form 2203 Revised Oct 2013</p><p>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. </p><p>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. </p><p>Page 4 of 4</p>