Survivors of Torture, International Client referral form
FAX: (619) 294-9405 Attn: Clinical Director Phone: (619) 278-2400 Referred by: Agency/office address: City Fax ( ) Phone ( State e-mail ) Zip Date
I wish to refer the person below for the following services (select one or more specific to this case): psychological Evaluation for Asylum ______health/allied health (Not Medical Eval) ___counseling ___case management
_____ Medical Evaluation for Asylum
If this request involves immigration proceedings, please note the information below: For Affirmative Cases, filing date For Defensive Cases, filing date: Judge: Affirmative interview date Date/Time of merits hearing: For all cases, last date attorney can accept completed reports: ___________________
PERSON BEING REFERRED
Last Name First Middle
Primary Phone Address Gender (Circle one): Country of Origin Female FTM Male
Secondary Phone/e-mail City __________________State MTF DOB SS# Zip
Age at intake
Ethnicity
Legal Status________________ (for asylum seekers, send declaration) Alien # Language(s): ______________ Interpreter’s name: Brief description of the alleged torture: __________________ Relation to client: Does this client speak English? Yes Phone ( ) some none
Brief description of the psychological effects of alleged torture:
Brief description of the medical effects of alleged torture:
Reported reason for torture:
Reported perpetrators of torture:
FOR INTERNAL USE ONLY: Date Received Staff completing review Client Number Eligibility established by ___ declaration ___interview ___health screening ___other ________________________________ ___ Client accepted services ___Client declined – Reason ___ Ineligible for services – Reason Date referred to Network Clinician Clinician: Phone/Fax: Date referred to Vol. Physician Physician: Phone/Fax:
Rev. 7/2007 CG