Domestic/family violence Gender based persecution ☐ ☐ Ethnic/racial/social persecution Slavery ☐ ☐ Extreme physical/psychological violence Solitary confinement ☐ ☐ Female genital mutilation Trafficking ☐ ☐ Forced Marriage Violations of liberty ☐ ☐ Gang based/inter-tribal/inter-clan violence Witness to atrocity ☐ ☐ Honour killings (threatened/attempted ☐ Other/Comments ______________________________________________________________________ Please give a history of your client’s experiences of human rights violations Referral Self-referral (If please answer the following questions) “no”, ☐Yes ☐No Referrer’s name Organisation Contact phone Contact email Relationship to client Reasons for referral to Room to Heal (Please include any physical or psychological health issues) What would individual like to gain by joining Room to Heal?
☐ Domestic/family violence ☐ Ethnic/racial/social persecution ☐ Extreme physical/psychological violence ☐ Female genital mutilation ☐ Forced Marriage ☐ Gang based/inter-tribal/inter-clan violence ☐ Honour killings (threatened/attempted ☐ Gender based persecution ☐ Slavery ☐ Solitary confinement ☐ Trafficking ☐ Violations of liberty ☐ Witness to atrocity Other/Comments ______________________________________________________________________ Please give a history of your client’s experiences of human rights violations Referral Self-referral ☐Yes ☐No (If “no”, please answer the following questions) Referrer’s name Organisation Contact phone Contact email Relationship to client Reasons for referral to Room to Heal (Please include any physical or psychological health issues) What would individual like to gain by joining Room to Heal?
RTH-Referral-Form-Updated-2018.docx