Call
0207 928 3462

MECS Refugees & Asylum-Seekers Referral: Client Details

*Please be aware this form is only for Refugees and Asylum-Seeking clients who are 18 years or older.* Please ensure all the boxes on your referral form are filled before you submit your referral and note that we cannot accept incomplete or partial referrals. If you prefer, you can download a Word version of the form here and fill it in and email it to us on info@waterloocc.co.uk
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
  • - Sexuality -
  • Bisexual
  • Gay
  • Heterosexual
  • Lesbian
  • Other Sexuality (Please specify)
Field is required!
Field is required!
  • - Ethnicity -
  • Asian Indian
  • Asian Pakistani
  • Asian Bangladeshi
  • Asian British
  • Asian other
  • Black Caribbean
  • Black British
  • Black African
  • Black other
  • Chinese
  • Chinese British
  • Chinese_other
  • Mixed White and Black Caribbean
  • Mixed White and Black African
  • Mixed White and Asian
  • Mixed other
  • Latin American
  • Middle Eastern
  • White British
  • White Irish
  • White European
  • White other
  • Other ethnicity (Please Specify)
Field is required!
Field is required!
  • - Disability -
  • Blind or visual impairment
  • Deaf or hearing impairment
  • Learning difficulty
  • Mental health
  • Mobility
  • Other disability (Please specify)
  • None
Field is required!
Field is required!
  • - Religion -
  • No religion
  • Christian
  • Buddhist
  • Hindu
  • Jewish
  • Muslim
  • Sikh
  • Other religion (Please specify)
Field is required!
Field is required!
  • - Housing status -
  • Tenant
  • Owner
  • Temporary accommodation
  • Homeless
  • Other housing status (Please specify)
Field is required!
Field is required!
Field is required!
Field is required!
Please indicate client's preferred language for counselling. We only offer counselling in the languages listed below.
  • Language Spoken
  • Albanian
  • Amharic
  • Arabic
  • Bengali
  • Cantonese
  • English
  • Farsi
  • Farsi (Dari)
  • French
  • Hindi
  • Italian
  • Kurdish
  • Mandarin
  • Pashto
  • Polish
  • Portuguese
  • Romanian
  • Russian
  • Somali
  • Spanish
  • Tamil
  • Tigrinya
  • Turkish
  • Twi
  • Urdu
Field is required!
  • - Immigration status -
  • ILR
  • Refugee
  • Asylum seeker
  • British citizen
  • EEA citizen
  • Undocumented migrant
  • Under appeal
  • Other Immigration status (Please specify)
Field is required!
Field is required!
  • Level of English
  • Fluent
  • Working
  • Basic
  • None
Field is required!
Can client receive counselling in English?
Field is required!

History of traumatic experiences of actual, threatened or witnessed torture and/or ill-treatment

Field is required!

Experience of living in exile

Field is required!

Risk of harm to self and/or others

Field is required!

Health problems & issues

Field is required!

Prior contact with counselling/psychiatric services or with GP for emotional/psychiatric problems

Field is required!
Field is required!
Upload supporting documents for Section E&F: reports, assessment notes, discharge letters, etc. Accepted file types; JPG & PDF.
Field is required!

Diagnosis, medication and dosage

Field is required!

Referrer Details

Please fill in all sections
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

GP Details

Please note that we cannot accept your referral if this section is not completed in full detail....
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
When you're happy with you Referral you can submit it using the button below. We aim to respond to referrals within 48 working hours. Our office hours are Monday-Friday, 9.30am-5.30pm, or Saturday, 10am-4pm. With thanks, The Team at WCC.



“I found therapy useful, particularly expressing my feelings in my language”

Client