Woodfield Trauma Service

(Previously known as Forced Migration TraumaService)

7A Woodfield Road London W9 2NW

Tel: 02072669575 Fax: 02072669576 Email:

Please note referrals will not be processed if there is not sufficient information given on all areas of this form.

When completed, please return to administrator using the contact details shown above.

Referral Information
Date of referral / Referral received by WTS (admin)
CLIENT INFORMATION
Family Name:
Other Names: / Date of Birth: (dd/mm/yyyy)
Gender: MALE  FEMALE  / NHS No (Must):
Full Address: / Dependants: (If known give details of names/ages of children and whether they live with client)
TelephoneNumber:
/ Marital Status:
Alternative contact: / Religion:
Country of Origin: / Is client aware of referral? Yes  No
Communication and Languages Details
Does the client speak English?Yes  No 
If the client requires an interpreter, please state language: ______
If required, does the client prefer a male or female interpreter? Male Female Either
Immigration Status
Refugee Status  Indefinite Leave to Remain  Unknown
Active Asylum Claim  Refused Asylum Seeker 
Other key people involved supporting the client
GP Name, surgery and address: / Tel:
Fax:
Other involved agency and address: / Tel:
Fax:
Other information
*Reason for Referral (Please give a short description of why this person has been referred)
Physical Health
Any physical health problems /treatment or investigations
Medication
Please list all current prescribed medication.
Housing
Please describe current situation or any problems.
Work/ Benefits
Is the person working or in receipt of any benefits? Are there any problems?
Risk Information
Any suicide attempts/ self harm or violence to others.
Information on Trauma and Associated Symptoms
Please describe nature of traumatic event(s) and date(s) if known:
What are the client’s symptoms of post-traumatic stress disorder? (re-experiencing, hyperarousal, avoidance etc.)
*Required – These are inclusion/exclusion criteria:
Does the client have PTSD to any events experienced after turning 16? Yes No 
Were they forced to leave their country of origin/home? Yes No 
Any other information
REFERRER INFORMATION
Referrer Name and Job Role
Agency Name / Telephone:
Email:

Please email to or post/ fax to the address/ fax number at the top of this form. Thank you for taking the time to complete this form.

Trust Headquarters: Greater London House, Hampstead Road, London, NW1 7QY

Telephone: 020 3214 5700 Fax: 020 3214 5701