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Confidential Domestic Violence Intake

Imigrus   →  Confidential Domestic Violence Intake

Confidential Domestic Violence Intake

Confidential Domestic Violence Intake

Confidential Domestic Violence Intake

⚠ Please do not use this form if you are in immediate danger. If this is an emergency, call 911 or seek immediate local help.

Confidential Domestic Violence Intake

If you have experienced domestic violence, threats, coercion, stalking, document retention, or related abuse, this confidential intake form helps us evaluate whether you may qualify for immigration relief, including possible U visa screening. Please complete as much as you can. If you do not have every document right now, you may still submit the form.

Section 1: Contact Information

Please fill out your contact information so we can reach you safely.

Section 2: Current Situation & Safety

Please describe your current situation as best you can. All information is kept strictly confidential.

Section 3: Immigration Status

Please provide information about your immigration and citizenship status.

Section 4: About the Abuser

Information about the person who harmed you. You may skip fields you are not comfortable answering.

Section 5: Documentation & Evidence

Please list any documentation you have or have had access to. You do not need to submit documents at this time.

Section 6: Legal History

Please share any information about legal proceedings or law enforcement involvement.

Section 7: Consent & Acknowledgment

By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge. All submissions are kept strictly confidential and protected under attorney-client privilege.

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