Doncaster Therapeutic Service (adults)

Please give the details relevant to adult being referred to the Refugee Council.

Date of Referral*

Confirm Consent has been given by client to be added to RC database*

First Name*

Family Name*

Date of birth*

Gender*

Age*

Current Address*

Telephone Number*

Name of phone contact (if different person as stated above)

Country of Origin*

Nationality/Ethnicity*

Preferred language*

Language of Interpreter

Interpreter required*

Date of arrival in the UK*

Date of arrival is estimated*

Financial support*

GP Name*

GP Address*

GP Telephone Number*

Refugee Council support worker (if known)*

Please provide a brief history of human rights violations, conflict prior to resettlement e.g. witnessing conflict, loss or disappearances of family members, torture, sexual violence & rape, trafficking, political persecution, gender-based violence*

Mental health Difficulties*

Other agencies involved (e.g. Community Mental Health Team, Social Services, domestic violence agencies etc.)*

Physical Health Issues*

Practical and/or Social Concerns*

Risk issues e.g. self harm, risk to others*

Priority of referral (urgent or non-urgent)*

Priority of referral

Name of Referrer*

Referrer Organisation

Referrer Job Role*

Organisation Address

Telephone Number of Referrer*

Email address of Referrer*