Detained Loved One Form
Use this form to submit a direct referral to the Centralized Referral System for Illinois residents who have been detained by ICE and need legal representation. Only one form is needed per detained individual. Complete the form to your best ability and select "Unknown" is unsure. An individual from our team will contact you within 48 hours if any additional information is needed and to discuss next steps.
Por favor haga clic aquí para ver esta forma en Español.
Have you previously called or submitted a referral for representation for this individual?
Yes
No
Have there been any changes since the first referral?
Yes
No
Please note that you only need to submit one referral form per individual. Our team will be in contact with the family member listed below within 48 hours.
Please share notes about what has changed
Your Information
Who will be filling out this form?
Please select...
Community Organization
Office of Elected Official
Family or Friend of Someone Detained
Name of Elected Office
Organization Name
Your Relationship to Detained Individual
First Name
Last Name
Email
Phone Number
Alternative Contact Information
What is your preferred language?
Please select...
English
Spanish
Other
Other preferred language
Consent to Share Information:
By selecting "Yes", you are acknowledging that this form will submit a referral request for legal advice or representation. This form does not confirm that the individual is guaranteed representation. You understand this form does not create an attorney-client relationship between me or the individual referred and any legal representative. This form is not considered legal advice. You understand that this information may be shared with other organizations in the network, not just the organization assisting in the referral.
Yes
No
Consent to Share Information is Required to Continue
Family Member or Friend Primary Contact
Please share information about the person who will serve as the primary contact related to the detained individual's case.
Relationship to Detained Individual
First Name
Last Name
Email
Phone Number
Alternative Phone Number
Additional Family Member or Friend Contact
Please share information about the person who will serve as the primary contact related to the detained individual's case.
Relationship to Detained Individual
First Name
Last Name
Email
Phone Number
Alternative Phone Number
Information About the Detained Individual
Detained Individual First Name
Include first and middle name if applicable
Detained Individual Last Name
Include both last names, if applicable.
If both names are not complete we may not be able to locate individual
Detained Individual Date of Birth
Month
Please select...
Unknown
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
Unknown
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
Unknown
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
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1976
1975
1974
1973
1972
1971
1970
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1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Birthday Year Calc
Birthday Day Calc
Birthday Month Calc
Date of Birth
Detained Individual Gender
Please select...
Male
Female
Transgender Male
Transgender Female
Other
A-Number (if applicable)
A-Number is the 8 or 9 digit number that you can find on immigration paperwork. It is usually labeled “A#” or “File No.” and posted prominently near the top of any immigration paperwork.
A-
What is their preferred language?
Please select...
English
Spanish
Other
Other preferred language
Country of Birth
Country of Nationality
When did the detained individual most recently enter the US?
What was the detained individual's last residence address prior to detention?
Last Residence Location
Illinois
Outside of Illinois
Last Residence State
Last Residence Street Address
enter 'unknown' if you do not know the exact address
Last Residence City
Last Residence City
Last Residence County
Phone, email or other contact information for detained individual
Does the detained individual have any urgent medical needs?
Yes
No
Unknown
Please provide additional information on urgent medical needs
Information About the Immigration Arrest
When did the arrest occur?
Month
Please select...
Unknown
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
Unknown
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2026
2025
Arrest Date
What time did the arrest occur?
Where did the arrest occur?
Please select...
Home
Work
School
While driving
On the street
Other
Please describe the arrest location
Which state?
Illinois
Outside of Illinois
Location of Arrest - State
Location of Arrest - City
Location of Arrest - City
Location of Arrest - County
Who Arrested the Individual?
Other Arresting Agency
Please provide a description of what happened
Any additional notes about the arrest or the individual that was detained?
Detained Loved One Form Detained Loved One Form