Refugee Claim Intake Form

Thank you for reaching out to us for assistance with your refugee claim in Canada. We understand that this can be a challenging and sensitive process, and we are committed to providing you with the support you need.

This intake form has been designed to help us gather essential information about your situation, which will enable us to better understand your circumstances and offer you appropriate guidance. Please complete the form to the best of your ability. Your answers will be treated with utmost confidentiality and will only be used for the purpose of assisting you with your refugee claim.

If you have any questions or concerns about the form or the process, please don’t hesitate to ask. Our goal is to ensure that you receive the assistance and guidance you deserve as you navigate this important step in seeking refuge in Canada.

Name *

First

Last

Have you ever used any other names or aliases? *

Email *

Phone Number *

Applicant's Age *

Applicant's Nationality *

Mailing Address

City

State / Province

Country

Postal Code

Are you in Canada right now? *

• Yes
• No

Please note: You can’t submit a refugee claim from outside Canada.

Do you have any identification documents, such as passports or birth certificates? *

Why do you believe you are at risk of persecution in your home country? *

What specific experiences or events have led you to fear for your safety? *

Provide specific incidents or events that have caused you fear or harm

Are you a member of a particular social, ethnic, religious, or political group that is being targeted? *

Have you experienced any threats, violence, harassment, or discrimination because of your beliefs, political opinion, race, nationality, religion, or membership in a particular social group? *

Can you provide specific examples of incidents that have caused you fear or harm? *

FAMILY STATUS *

• Single
• Common-Law (lived togetherfor at least one year)
• Married
• Conjugal (have been in a committed relationship for at least one year, but due to reasons beyond your control, could not live together)
• Other

Do you have any children or dependents? If so, please list and include age of each child or dependent. *

Are any of your family members also facing persecution? *

Have any family members already sought asylum in Canada or another country? *

How did you arrive in Canada? Did you travel alone or with others? *

What route did you take? Were you assisted by any individuals or organizations along the way? *

Did you encounter any difficulties, dangers, or challenges during your journey? *

Have you sought protection or assistance from your home country's authorities? Why, or why not? What was the outcome? *

Have you tried to seek refuge in any other country before coming to Canada? If yes, which countries and what was the outcome? *

Do you have any photographs, documents, letters, or other evidence that supports your claims? *

Are there witnesses who can verify your story? If so, who are they and how can they be contacted? *

Do you have any physical or mental health issues that are a result of your experiences in your home country? *

Have you received any medical treatment for these issues? *

How do you plan to support yourself while your refugee claim is processed?

• I plan on working
• I plan on studying
• I'm not sure

Do you need assistance with applying for a work permit, or a study permit?

• Yes I need assistance
• No I don't
• I'm not sure

Are there any organizations or individuals in Canada who are assisting you? *

Are there any organizations or individuals in Canada who are assisting you? (copy) *

Are you aware of the legal process and the steps involved in making a refugee claim in Canada? *

What other relevant information would you like to add about your immigration situation? *

Confirmation *

• I acknowledge that I have provided honest and complete information. I understand that all information will be kept strictly confidential.
• I acknowledge that submitting this form does not mean that Zaidi Legal PC has been retained and I acknowledge that there is no solicitor-client relationship until formal requirements are met.

Submit