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MICHAEL J. GURFINKEL, INC.

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Page 1 of 10
Law Offices of
MICHAEL J. GURFINKEL, INC.
INITIAL INTAKE QUESTIONNAIRE
This is a one-time consultation, limited to the specific question or problem for the particular person submitting this
questionnaire, based on existing facts and law. If there are new or additional problems or issues with respect to the person, future
changes or differences in law or facts, and/or another person’s problems, then a new consultation (and a new consultation fee) will
be required.
WHO ARE YOU SEEKING LEGAL ADVICE ABOUT? (i.e. who wants the visa, was denied, is in
removal, etc)?
About myself and my own immigration situation
- Please fill out the questionnaire concerning your own situation or problems.
About a friend or relative’s immigration situation
- If you are making inquiries about another person’s case or problems (i.e. your friend or relative), please provide
information about the person you are inquiring for, NOT ABOUT YOURSELF (i.e. pretend you are the person on
whose behalf you are making the inquiry, and answer as though he/she was filling out the question himself/herself).
Did the person with immigration problem (“Client”) ever have a previous consultation with our office?
Yes No
If so, what is the Client’s name who previously consulted with us? _______________________________
What was the approximate date of the consultation? ___________________ _____________
Month Year
1. a. Client’s Full Name (Exactly as it appears on the birth certificate):
_________________________________________________________________________________
Last First Middle/Maiden
b. Name Client is currently using: Same as above
_________________________________________________________________________________
Last First Middle/Maiden
INFORMATION ABOUT PERSON WITH IMMIGRATION PROBLEM (“CLIENT”)
PLEASE DO NOT WRITE/PRINT ON BACK OF PAGES
NO PERSONAL CHECKS are accepted for Initial Consultations.
Payments can be made in Money Order, Cashier/Manager’s Check, Zelle (via: payments@gurfinkel.com), Cash or Online
Payment (Credit/Debit Card) thru our website: www.gurfinkel.com.
It is important to the evaluation of the case that you complete this Questionnaire accurately, truthfully and completely.
We assure you that the information supplied by you (whether or not you retain our services) is strictly confidential.
PLEASE PRINT LEGIBLY, USING BLUE or BLACK INK.
S:\Reception\Forms\Intake-questionnaire Revised 9/10/2021 /cp
Prior to filling up the form, please save this file to your computer.
Page 2 of 10
2. Other names used (Maiden, Married, Religious, Professional, Assumed, Aliases): None
_________________________________________________________________________________
Last First Middle/Maiden
3. Did client enter the U.S. under an “assumed or fake name”? Yes No
_________________________________________________________________________________
Last First Middle/Maiden
4. Client’s Present Address:
_________________________________________________________________________________
(No. / Street / Apt. No. / City / State / Zip Code / Country)
5. Client’s Telephone Numbers in Philippines and/or U.S.:
Cell Number: (_____) __________________
Best time to reach you: _____________
Alternate Number: (_____) _______________
E-Mail address: _________________________
6. Alternate contact person for client in U.S. in case client cannot be reached:
(Should be different from client’s contact info.)
___________________________________________________________________________________
Last First Middle/Maiden
__________________________________________________________________________________
(No. / Street / Apt. No. / City / State / Zip Code)
Relationship to Client: __________________________
(_____) _______________
______________________________
Cell Email
7. Client’s Date of Birth: _________________________________________ Age: ________
8. Client’s Birthplace: ________________________________________________________________
City Province/State Country
9. Client’s Present Nationality or Citizenship (Country): ____________________________________
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Page 3 of 10
10. Client’s Marital Status
a. Has client ever been married (whether Church, civil, or “secret” marriage)? YES NO
b. If yes, how many times: __________________________
c. Client’s present marital status: Single Married Divorced Widow(er) Annulled
d. Marital History:
i.
Date of (1st) Marriage: _________________________ Place of (1st) Marriage: ____________________
- If divorced/annulled,date: __________________ Place: ______________________________
ii.
Date of (2nd) Marriage: _____________________ Place of (2nd) Marriage: _______________
- If divorced/annulled,date: __________________ Place: ____________________________
If you have additional marriages, please provide information on a separate sheet.
INFORMATION ABOUT CLIENT’S FAMILY
11. Spouse’s Name: NONE _________________________________________________
Spouse’s Nationality/Citizenship: ________________________________________________
Date of Birth: ______________________________ Place of Birth: _____________________________
Is your spouse in the U.S.? Yes No
If no, specify Country where spouse resides (i.e. Philippines, etc.): ____________________________
Was your spouse ever married before, or does he/she have children? Yes No
12. Children’s Info: NONE
Name Country of Date of Age Specify where client’s
Birth Birth child is (U.S./Phil.)
1. __________________________________ ___________ ___________ _____ _______________
2. __________________________________ ___________ ___________ _____ _______________
3. __________________________________ ___________ ___________ _____ _______________
4. __________________________________ ___________ ___________ _____ _______________
5. __________________________________ ___________ ___________ _____ _______________
6. __________________________________ ___________ ___________ _____ _______________
If you have
additional children, please
provide information on a separate sheet.
Are any of these children adopted, given, stepchild, etc. (i.e. not the client’s biological child)?
Yes No
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Page 4 of 10
CLIENT’S EDUCATION / EMPLOYMENT INFORMATION
CLIENT CLIENT’S SPOUSE
13. Did
client (or client’s spouse) graduate high school in
Yes No Yes No
the U.S., currently enrolled in school in the U.S.,
obtained a GED certificate, or served in the U.S.
Armed Forces or Coast Guard?
Is client (or client’s spouse) a college graduate? Yes No Yes No
Degree/Major: _______________ ________________
Does client or client’s spouse have any special skills or work experience (i.e. specialty cook, auto
mechanic, executive secretary, office manager, etc.) either in the U.S. or abroad? If so, describe:
CLIENT: NONE ______________________________________________________________
CLIENT’S SPOUSE: NONE _____________________________________________________
14. If client is seeking a working visa, is there an employer in the US who is willing to sponsor/petition
client (or client’s spouse) for a working visa/green card?
Yes No
CLIENT’S ENTRY INFORMATION
15. a. What is client’s present U.S. immigration status:
Never been to U.S. (If client has never been to the U.S., please go to Question # 18)
U.S. Citizen Political Asylum
Immigrant/Green Card Holder CSS/LULAC
B-1/B-2 (visitor) TNT or Out of Status
F-1 (student) Other: _______________________________
N/A
15. b. Date you most recently entered/arrived in the U.S.: ________________________________________
15. c. If client is presently in the U.S., what is/was expiration date on client’s I-94 (white arrival\departure
card given to non-immigrants, such as visitors, at time of entry to U.S.): _________________________
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Page 5 of 10
YES NO
16. a. Was client “physically present” in the U.S. on 12/21/00?
16. b. How did client enter the U.S. on most recent trip?
CLIENT CLIENT’S SPOUSE CLIENT’S CHILDREN
Valid Visitor’s Visa
Under a Different Name
Jump Ship
No Inspection (w/o visa)
Other (Specify) _____________ _________________ ___________________
17. Did client ever:
Yes No
Yes No
Allow his/her visa, I-94, or extension to expire (even for one day)?
Depart the U.S. on “advance parole”?
If yes, when: _________________________________
18. Has client (or client’s spouse) ever been denied a Visa, Petition, Labor Certification, or any other
immigration benefit for which client applied (i.e. Political Asylum, CSS/LULAC, Visitor’s Visa,
Family Petition), has client’s visa ever been cancelled, or has client otherwise been found ineligible for
any visa or immigration benefit?
Yes No (Do not write N/A)
If yes, please explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Page 6 of 10
19. Has client (or client’s spouse) ever been placed in Deportation, Exclusion, or Removal proceedings,
ordered deported, been questioned/interviewed by DHS, or did not attend a deportation hearing
(ordered deported in absentia) or ever been inside a courtroom?
Yes No (Do not write N/A)
If yes, please explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
20. Has client (or client’s spouse) ever been arrested, handcuffed, placed in the back seat of a police
car, accused of, charged with, convicted of, or questioned by a law enforcement officer about, any
crime or other illegal activity in the US or in any other country, no matter how long ago it
occurred? (This would also include situations such as domestic violence/spousal abuse, shoplifting,
embezzlement, theft, or where a person was charged with a crime and accepted a “plea bargain”,
had a conviction “expunged”, or had the charges “dropped” by law enforcement.)
Yes No (Do not write N/A)
If yes, please explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
21. Has client (or client’s spouse) ever had an application or petition filed with the INS, USCIS, DHS,
DOL, etc. for any of the following?
NONE (Check “NONE” only if all items are not applicable)
CLIENT CLIENT’S SPOUSE
a. Family Petition
b. Labor Certification
c. H-1 (working visa)
d. Motion/Appeal
e. CSS/LULAC/SAW
f. Political Asylum
g. Other (Specify): _________________ ____________________
Did client ever get a work permit from INS or CIS? Yes No
How was work permit obtained (i.e. what benefit did client apply for, which resulted in having been
granted work authorization? ________________________________________________
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Page 7 of 10
22. Does client (or client’s spouse) have any of the following relatives who are U.S. citizens or green
card holders? (Please indicate if this relative is deceased by putting “D” by that relative.)
NONE (Check “NONE” only if all items are not applicable)
CLIENT: Mother Father Spouse Child Brother/Sister
American Citizen
Green card holder
CLIENT’S SPOUSE: Mother Father Spouse Child Brother/Sister
American Citizen
Green card holder
Do you have a spouse, parent, or child
who has ever served in the US Armed Forces? YES NO
23. Were any of the following relatives BORN in the U.S., or naturalized before the BIRTH of client
(or client’s spouse)?
NONE (Check “NONE” only if all items are not applicable)
Mother Father Grandmother Grandfather Great-grandparents
If grandparents were citizens, did grandparents become U.S. Citizen BEFORE your parent’s
birth?
Yes No
24. Did client or client’s spouse ever make any misrepresentations (changed marital status, changed age,
altered name, etc.) to an immigration or consular officer to be able to acquire a visa or other
immigration benefit or to enter the U.S.?
Yes No (Do not write N/A)
If yes, please explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Page 8 of 10
2
5
. Did cl
ient or
client’s
spouse
ever
sign
any
affidavit,
confession,
or
other
document for the INS/USCIS
or Embassy admitting fraud or ineligibility for any immigration benefit, or was client ever told their
case was being “investigated” for fraud or other ineligibility?
Yes No (Do not write N/A)
If yes, please explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
26. Are there any upcoming deadlines or due dates on client’s immigration case (i.e. court hearing,
interview, response to INS/USCIS, etc)?
Yes No (Do not write N/A)
If yes, please provide due date and explain reason.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Page 9 of 10
27. Has an IMMIGRANT visa petition ever been filed on client’s (or client’s spouse’s) behalf?
(Employment Based / Family Based)
NONE (Check “NONE” only if all items are not applicable)
For client? Yes No
For client’s spouse? Yes No
When was the petition filed (priority date)? _________________________________
Month Day Year
If an IMMIGRANT visa petition has been filed, who filed it?
Parent Spouse Brother/Sister Child Employer
What Preference Category?
Immediate Relative (Spouse, Parent, Minor Child (under 21) of U.S. Citizen)
F-1 (Adult (over 21), Unmarried Child of U.S. Citizen)
F-2A (Spouse/Minor Child of Immigrant)
F-2B (Adult, Unmarried Child of Immigrant)
F-3 (Married Child of U.S. Citizen)
F-4 (Brother/Sister of U.S. Citizen)
Employment/Labor Certification
Were client’s (or client’s spouse’s) parents ever petitioned for a green card (i.e. by a relative or
employer) while client was under 21 years of age? YES NO
28. Has client ever consulted with or retained any attorney or law firm in connection with any
immigration matter?
Yes No
If yes, name of attorney or law firm: __________________________________________________
29. a. Does client have an “Alien Number” (8 or 9 digit number on a green card, work authorization, etc.)
NONE _______________________________________
b. Does client’s spouse have an “Alien Number” number? NONE _____________________
c. How was the “Alien Number” obtained? N/A (Check this only if client never had Alien #)
Family Petition Employer Petition Asylum Other _____________
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Page 10 of 10
30. Briefly describe the nature of the immigration problem and type of legal assistance required (i.e.
want working visa, deportation defense, family petition, previously denied a visa, appeal etc.):
NOTE: PLEASE DO NOT LEAVE THIS ITEM UNANSWERED.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
PLEASE READ:
No attorney-client relationship shall exist between client and this office by virtue of this questionnaire or consultation, unless
and until client formally retains our services pursuant to a written retainer agreement, signed by us, and client pays any
applicable attorney fees and costs for such services. There may be deadlines, due dates, court hearings, interview dates, etc., in
connection with the case. However, this consultation and/or your submitting this questionnaire does not obligate our office to
represent client, make any appearances, file any documents, or provide any legal services on client’s behalf. No prediction,
warranty, or guarantee can be made on the outcome of your case. Our advice during the consultation constitutes our opinion
concerning the merits or chances with respect to your case. Client is certainly free to seek a second opinion from another
attorney concerning his\her case and outcome.
PHONE CONSULTATIONS: Please EMAIL completed questionnaires to consult@gurfinkel.com. If sending by MAIL,
client or representative should sign the Intake and send directly to our main office at 219 North Brand Boulevard, Glendale,
CA 91203, and not to branch offices. If located in the Philippines, mail the questionnaire to our Makati office. Please only
send COPIES of documents, NOT ORIGINALS, as they will not be returned.
IN-PERSON CONSULTATIONS: Please bring completed questionnaire and COPIES of documents with you, especially
denials, approvals, filing with DHS that you are consulting about. Please sign before submitting the questionnaire. Do not
mail to our office.
One of our attorneys will contact you in connection with your consultation. Even though it might not be Attorney Gurfinkel, he
still oversees and supervises all cases and case strateg
y.
AUDIO/VIDEO RECORDING is NOT allowed.
DATE CLIENT’S (or Representative’s) PRINT CLIENT’S
SIGNATURE (or Representative’s) FULL NAME
*Once this box is checked, you can no longer make changes.
By checking (or clicking) this box, you certify that the answers you furnished on this form are true and correct to the best
of your knowledge and belief. You understand that any false or misleading statements may result in the permanent refusal
of a visa, or denial of entry into the United States. Clicking this box shall constitute your "online signature."
S:\Reception\Forms\Intake-questionnaire Revised 9/10/2021 /cp
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MICHAEL J. GURFINKEL, INC.

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Completed 7 February 2022

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