MEDICAL FOUNDATION – MEDICO LEGAL REPORT SERVICE

CASE REFERRAL FORM

Must be Completed in Full

PLEASE FAX TO 0207 697 7740 (DETAINED FAST TRACK ONLY OR BY EMAIL TO )

ALL OTHERS BY POST OR BY EMAIL TO

CLIENT DETAILS:

TITLE: (MR/MRS/DR/MS/ MASTER/ MISS)

FIRST NAME:

LAST NAME:

DATE OF BIRTH:PLACE OF BIRTH:

MARITAL STATUS: (SINGLE/MARRIED/ WIDOWED/ DIVORCED/CIVIL PARTNERSHIP)

ADDRESS:MOBILE NUMBER:

GENDER: MALE/FEMALE/OTHER:

NATIONALITY:ETHNICITY:

RELIGION:LANGUAGE:

HO REFERENCE:PORT REFERENCE:

DATE LEFT COUNTRY OF ORIGIN:

DATE OF ARRIVAL IN UK:

DATE OF ASYLUM CLAIM:

INTERVIEWED BY HOME OFFICE: YES/NO DATE:

REFUSED:YES/NODATE:

APPEAL DATE (If applicable):

(ONLY COMPLETE THIS PART IF YOUR CLIENT IS DETAINED)
PLACE OF DETENTION:
HARMONDSWORTH: ( )
YARLSWOOD: ( )
OTHER: (PLEASE SPECIFY)
IS CLIENT IN DETAINED FAST-TRACK? YES/NO

LEGAL REPRESENTATIVE’S DETAILS

SOLICITOR’S FIRM AND ADDRESS:

SOLICITOR’S FAX NUMBER:

DIRECT LINE:

MOBILE:

SOLICITOR’S REFERENCE NUMBER:

SOLICITOR/CASEWORKER WITH CONDUCT OF MATTER:

TYPE OF REPORT REQUESTED:

PHYSICAL AND/OR PSYCHOLOGICAL CONSEQUENCES (MLR) ( )

THERAPEUTIC (PSYCHIATRIC/ COUNSELLING/PSYCHOTHERAPY – FOR PATIENTS ALREADY IN TREATMENT AT FREEDOM FROM TORTURE) ( )

GIVE DETAILS OF ANY SPECIAL INSTRUCTIONS:

IS THERE A DEADLINE FOR THIS REPORT? (PLEASE STATE DATE):

NATURE OF CASE

DETAINEDYES/NO

DETAINED FAST TRACKYES/NO

NON DETAINEDYES/NO

NON DETAINED PILOTYES/NO

THIRD COUNTRYYES/NO

NON-SUSPENSIVE APPEALYES/NO

DETAINED CRIMINAL CASEWORKYES/NO

APPEAL RIGHTS EXHAUSTED/

PENDING REMOVALYES/NO

FRESH CLAIMYES/NO

DETENTIONS AND OTHER ILL TREATMENT IN COUNTRY OF ORIGIN: (A DETAILED NARRATIVE OF CLIENT’S ACCOUNT SUCH AS A WITNESS STATEMENT OR SEF INTERVIEW RECORD IS NECESSARY AS A MINIMUM. PLEASE DIRECT US TO RELEVANT PARAGRAPHS/ANSWERS IN THE CLIENT’S DOCUMENTS)

HOW MANY TIMES:WHEN:

WHERE ARRESTED:

REASONS FOR ARREST:

BY WHOM:TAKEN TO:

FOR HOW LONG:

RELEASED: HOW/WHY

DESCRIPTION OF TORTURE(AS TAKEN FROM THE DOCUMENTS. PLEASE MAKE CLEAR WHICH DOCUMENT IS BEING REFERRED TO)

DOCUMENT/PAGE

SUSPENDEDYES/NO

SUFFOCATEDYES/NO

SUBMERGEDYES/NO

KEPT NAKEDYES/NO

SEXUAL ASSAULTYES/NO

BURNTYES/NO

CUTYES/NO

ELECTRIC SHOCKYES/NO

TOE NAILS/FINGERNAILS REMOVEDYES/NO

FALAKA (BEATING ON SOLES OF FEET)YES/NO

BEATEN/KICKEDYES/NO

LOST CONSCIOUSNESSYES/NO

SOLITARY CONFINEMENTYES/NO

OTHER (PLEASE SPECIFY)

PHYSICAL EVIDENCE OF TORTURE(PLEASE DETAIL ANY SCARS OR OTHER PHYSICAL CONSEQUENCES OF TORTURE BY DIRECTING US TO THE RELEVANT DOCUMENTS)

PSYCHOLOGICAL CONDITION(EG, NIGHTMARES/DISTURBED SLEEP/ABNORMAL BEHAVIOUR/SELF-HARM/FLASHBACKS/PAIN/RELATIONSHIP PROBLEMS ETC.)

MEDICAL TREATMENT

ANY TREATMENT/SURGERY IN COUNTRY OF ORIGIN? YES/NO

IF YES, GIVE DETAILS

ANY TREATMENT/SURGERY IN UK?YES/NO

IF YES, GIVE DETAILS (PLEASE INCLUDE PSYCHIATRIC TREATMENT IF APPLICABLE)

NAME/ADDRESSAND TELEPHONE NUMBER OF GP:

RULE 35 (APPLICABLE ONLY IF CLIENT IS DETAINED): HAS AN ALLEGATION OF TORTURE FORM BEEN SUBMITTED ON CLIENT’S BEHALF? YES/NO

IF YES, PLEASE ATTACH DETAILS AND UKBA RESPONSE:

DOCUMENTS REQUIRED: (PLEASE ATTACH THE FOLLOWING DOCUMENTS. WE ARE NOT ABLE TO ACCEPT A REFERRAL WITHOUT ALL OF THE DOCUMENTS LISTED BELOW THAT ARE INTHE POSSESSION OF THE UKBA AT THE TIME OF THE REFERRAL.PLEASE INDICATE WHICH DOCUMENTS ARE ATTACHED)

WITNESS STATEMENT (SIGNED AND DATED)YES/NO

SCREENING INTERVIEWYES/NO

SEF INTERVIEWYES/NO

IF NO, DATE OF SEF INTERVIEW

UKBA DECISION LETTERYES/NO

DETERMINATIONYES/NO

ANY OTHER MEDICAL EVIDENCEYES/NO

COPY OF ANY FRESH CLAIM FOR ASYLUM YES/NO

ANY OTHER REPRESENTATIONS SUBMITTEDYES/NO

OTHER INFORMATION

HAS CLIENT BEEN PREVIOUSLY REFERRED TO

MEDICAL FOUNDATIONYES/NO

IF YES, WHEN:IF KNOWN, CLIENT NUMBER:

IS CLIENT LEGALLY AIDEDYES/NO

INTERPRETER REQUIREDYES/NO

INTERPRETER GENDER PREFERENCEMALE/FEMALE/EITHER

DOCTOR GENDER PREFERENCEMALE/FEMALE/EITHER

1