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MECS Refugees & Asylum-Seekers Referral: Section A

*Please be aware this form is only for Refugees and Asylum-Seeking clients* 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
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  • - Gender -
  • Female
  • Male
  • Transgender
  • Other Gender (Please specify)
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  • - Sexuality -
  • Bisexual
  • Gay
  • Heterosexual
  • Lesbian
  • Other Sexuality (Please specify)
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  • - 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)
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  • - Disability -
  • Blind or visual impairment
  • Deaf or hearing impairment
  • Learning difficulty
  • Mental health
  • Mobility
  • Other disability (Please specify)
  • None
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  • - Religion -
  • No religion
  • Christian
  • Buddhist
  • Hindu
  • Jewish
  • Muslim
  • Sikh
  • Other religion (Please specify)
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  • - Housing status -
  • Tenant
  • Owner
  • Temporary accommodation
  • Homeless
  • Other housing status (Please specify)
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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
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  • - Immigration status -
  • ILR
  • Refugee
  • Asylum seeker
  • British citizen
  • EEA citizen
  • Undocumented migrant
  • Under appeal
  • Other Immigration status (Please specify)
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  • Level of English
  • Fluent
  • Working
  • Basic
  • None
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Can client receive counselling in English?
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MECS Referral: Section B

History of traumatic experiences of actual, threatened or witnessed torture and/or ill-treatment
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MECS Referral: Section C

Experience of living in exile
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MECS Referral: Section D

Risk of harm to self and/or others
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MECS Referral: Section E & F

1 (E).Health problems/issues. 2 (F).Prior contact with counselling/psychiatric services or with GP for emotional/psychiatric problems
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Upload supporting documents for Section E&F: reports, assessment notes, discharge letters, etc. Accepted file types; JPG & PDF.
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MECS Referral: Section G

Diagnosis, medication and dosage
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MECS Referral: Section H

Referrer details
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MECS Referral: Section I

GP contact details - Please note that we cannot accept your referral if this section is not completed in full detail....
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Checklist

I have completed in full detail the folllowing sections...
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For section E, If relevant, I have uploaded scanned or PDFs of reports, assessment notes, discharge letters, etc. detailing psychiatric issues.

For section F, If relevant, I have uploaded scans or PDFs of reports, assessment notes, discharge letters, etc. detailing prior contact with counseling/psychiatric services or with GP for emotional/psychiatric problems.

If preferred copies of these documents, for sections E & F, can be sent on by post. Please make sure to mark all documents appropriately so they can be associated to the correct Referral. It is recommended that copies, not original documents, be sent as we can not guarantee safe arrival or return of original documents via the postal service.

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