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BHRAC Medical Evaluation Request Form
Your request will be processed by the BHRAC team, and you will be notified within 3-8 business days regarding whether or not BHRAC is able to evaluate your client.
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* Indicates required question
Email
*
Your email
Agency, Firm or Organization:
*
Roger Williams Immigration Clinic
Sojourner House
Clinica Esperanza
Law Office of Marcela Ordonez
AMOR
Law Office of George A Pliakas
Dorcas International Institute
Refugee Dream Center
Other:
First Name:
*
Your answer
Last Name:
*
Your answer
Please provide a phone number for urgent matters or questions. Email will be our primary mode of communication.
*
Your answer
Office address
Your answer
Please check this box if you are a student attorney.
You will be asked to provide contact information for the supervising attorney pending BHRAC case acceptance.
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