Detained Representation Referral

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CHECK REFERRAL STATUS IF YOU HAVE ALEADY SUBMITTED AN APPLICATION BY CLICKING HERE OR CALL 833-468-4664/833-HOU-IMMI

Houston Area Detention Facility

"A" Number

Does this individual plan to reside in Harris County?

YesNo

Street Address

This is the street address where the detainee plans to reside upon release from detention.

City

This is the street address where the detainee plans to reside upon release from detention.

Harris County Zip Code

This is the street address where the detainee plans to reside upon release from detention.

Household Information

Number of People in Household

Household Annual Income

Detainee Information

Full Legal Name as listed on Birth Certificate

First

Middle

Last

Date of Birth

Month

Day

Year

Country of Origin

Language

Court Information

Link to Immigration Court Website: Automated Case Information (justice.gov)

Court Date (if available)

Does this individual have a bond set?

YesNoUnknown

Bond Amount (if known)

Is this individual a lawful permanent resident (LPR)/Green Card holder?

YesNoUnknown

Has this individual lived in the United States for at least 10 years?

YesNo

Is this individual afraid to return to their home country?

YesNo

Person Submitting Form

First Name

Last Name

Phone Number

Organization Submitting Form

Add Submission Notes

Is the person completing this form the detainee's primary contact?

YesNoPlease note that the primary contact may be different from the person submitting the form. The primary contact will receive further communication regarding this detainee.

Primary Contact Information

First Name

Last Name

Phone Number