Referral Form — The Refugee Therapy Centre

Date of Referral

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Female

Male

Other

Prefer not to specify

Marital Status

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Languages Spoken

Please list all languages spoken, and fluency (good, average, poor)

Country of Origin

Immigration Status

Name, address and contact details of next of kin

If the client being referred is a minor

Details of registered GP practice

Please include: Practice name, contact doctor, address and phone number

Referral Details - Reasons for referral

Please provide reasons for referral, in as much detail as you are currently able

Referral Details - Clinical history

Please provide history of mental heath interventions received (if applicable)

Referral Details - Medication

Please provide details of any medication you are currently on (if applicable)