Which centre are you making the referral to?
Separated from their family?
Is this a self-referral?
Referrer details
Are you an NHS Provider?
Max length - 800 characters
Client details
Max length 255 characters
Please provide one of the following
Client knows date of birth
As date of birth is not known, please pick one of the following
Is client age disputed?
...as defined by client
Need for interpreter
Client immigration Status
If exact day in the month is not known, please pick 1.
Max length - 800 characters.
Does the client currently have a legal representative?
GP
Please provide details of client’s life prior to arriving in UK, please provide as much detail as possible about the client’s history of torture/organised violence. Please include the dates and duration, why it occurred, what happened and who it was perpetrated by.
Current Difficulties
Does the referee have a disability?
Current Risk Factors
Please provide family details, specifying whereabouts of family members and nature of relationship with client.
Please provide details of client’s social networks and activities including community, religious, educational, vocational and their level of engagement.
Other agencies
Has the client given consent for this referral to be made and for the agencies listed on this form to be contacted if necessary?
Has the client given consent to contact their Legal representative and the Legal representative to provide FfT information about their case?
Optional Attachments
Maximum 3 files.
32 MB limit.
Allowed types: jpg bmp pdf doc docx.
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