Detainee/Former Detainee Assessment and Referral Form Referral Details Referring agency Referral date Detention Visit (Yes/No) Centre/Facility Name/Location Telephone assessment (Yes/No) Worker contact details Reason for referral Client Details First name Surname Date of birth Gender Address Phone number(s) Country of origin Language Interpreter Required Yes No Details Ethnicity Religion Family composition Name Relationship (eg, son) Date of birth Country of birth Genogram and/or any other relevant family information Immigration History Visa on arrival Date of arrival Date of any previous visits to the country Has client visited or had contact with UNCHR Date asylum application/unhcr lodged File number or client ID number (preferable) Current stage of refugee states determination process History of applications/appeals Asylum Claim details (Use separate form)
2 Current visa (Yes/No) and expiry date Current work rights Yes/No Compliance/reporting requirement Detention History/Circumstances Is the person detained? Yes/No Date detained Location (Incl. Transfer details) Detaining authority Detained on what grounds? Reason for detention given in writing Yes/No Previously detained Yes/No If yes, detention history and grounds for community release/raid experience Issues related to treatment/conditions while in detention. (See Appendix 1: Detention Standards Check List) Complaint made? To whom / Outcome Legal Legal representative Contact Issues impacting upon current legal situation Brief description of circumstances leading to protection application (claim) Issues experienced with past legal advice/representation Other immigration issues (not relating to asylum claim) List of legal documents sighted/copied by assessing agency: Passport Visa/Visa Papers Initial protection visa application and supporting material Decisions made Other submission and supporting documentation Other:
3 Health and Welfare Income Access to income Access to employment Housing Current housing situation Current or pending housing issues Children Are their children involved (Yes/No) Unaccompanied minors (Yes/No) Separated minors (Yes/No) Are the caregivers in the country (Yes/No) Have the child welfare authorities been contact/aware of the case? Has a Best Interest Determination (BID) been undertaken? Has efforts been made to reunite then children with their caregivers/release into community arrangements or other alternatives to detention? Health Healthcare Eligible Yes/No Current G.P Access to adequate health care Current health concerns (physical health, mental health) Current medications Significant previous health issues Indication of torture and trauma issues Counsellor (requested or current) Psychiatrist Family Family support available in the country?
4 Indication of missing or displaced family members/ assistance sought Other Supports Any other support available, including links to community, social and recreational groups and activities, detention visitors etc. Indication of any other particular vulnerabilities Domestic violence Mental health Risks of exploitation Social isolation Information Provision (Note client consent is required to transfer information to another agency) Awareness of refugee application and determination process Consent form given and signed- Agency information given and explained Information provided (where appropriate) regarding: Material aid services Education: schools, courses Other.. Other Agency Involvement Agency Worker Contact Details Role Action taken and referrals made to: Client consent: I...consent to the information provided above to be shared with the following agencies/individuals.. This information shall not be provided to third parties or other individuals not listed above. I may at any time change my mind and not allow this information to be forwarded to others. Name.Sign.Date Additional assessment resources: Children's Best Interest Determination Guidelines - UNHCR Heightened Risk Assessment Tool IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings See below an outline of a Psychosocial Assessment Summary
5 Area of assessment Psychosocial Assessment Summary Specific areas for comment Notes / Comments - Use space provided and additional pages as required Daily functioning Class attendance Class environment Familiarity with neighbourhood Practical needs and obstacles Household and other daily tasks such as taking children to school, shopping Level of participation in daily tasks and socially Family functioning Intactness of family Relationship between parents/caregivers Decision making roles Demands, conflicts Mutual support within the family Bonding with children Expectations of children Family safety, strengths, skills Emotional tone Guidance and discipline Psychological state of parents Children s well-being School attendance/performance/behaviour Relationship with parent/care giver Sibling relationships Peer relationships Everyday behaviour at home: emotional distress (excessive anger, crying) and sleeping, eating, nightmares, aggression, withdrawal, regressive behaviours Internal resources Response to reassurance Capacity to self-regulate emotions Self-esteem Sense of safety and security Developmental history Background experience: traumatic events Extent of exposure to violence and displacement Length of time spent under conditions of violence, displacement and hardship Any history of detention
6 Area of assessment Specific areas for comment Notes / Comments - Use space provided and additional pages as required Background experience: general Educational history Occupational history Religion Political activism Ethnicity Social networks and support Friends and neighbours Community Place of worship Interests and goals Immediate and longer-term goals Likes, enjoyable activities Expectations for self and family Employment and further education/training interests Psychological symptoms seriously interfering with daily life Anxiety Worrying all the time (may be expressed as head hurting) Sleep disturbance very little, too much, avoiding going to sleep Inability to concentrate, memory difficulties Nervousness and irritability Psychosomatic complaints Depression Mood Level of interest Hopefulness Appetite Energy Decision making Self-blame
7 Area of assessment Specific areas for comment Notes / Comments - Use space provided and additional pages as required Symptoms of intrusion and over-arousal Recurring memories Nightmares Flashbacks Sensitivity to reminders Hypervigilance Irritability Signs of numbing Avoidance of: Reminders Thoughts Feelings Situations Activities Substance abuse Other Evidence of: Guilt Shame Shattered assumptions Aggression Psychotic symptoms Suicidality Interpersonal and personality functioning (not family specific) Trust Suspiciousness Dependency and independence Sociability Hostility Strengths Physical health concerns Torture and trauma related other
8 International Detention Coalition Checklist of Detention Standards Treatment Protection Measures Allegations of torture and ill-treatment Use of force or other means of restraint Use of solitary confinement Information Provided to Detainees What information is given to detainees upon arrival? Accessibility to internal rules and procedures of the detention centre or facility Access to attorneys or interpreters Access to NGOs Access to the Asylum Procedure What information is given to the detainee regarding his or her right to asylum? In what language? For persons who cannot read or write, how is the right to asylum explained? What access to UNHCR and NGOs do detainees have? Are lawyers available to speak with and to represent detainees? When and under what conditions? What access do lawyers have to the detention centre or facility? What access to interpreters do detainees have? Are asylum interviews conducted in the detention centre or facility? If so, under what conditions? Is there privacy? Where are the interviews held? Disciplinary procedure and sanctions What are the procedures for disciplinary actions against detainees? What are the sanctions for violating the rules? Who determines whether a detainee violates the rules? What is the composition of the disciplinary authority? Are there possibilities of appeal? What are the sanctions? Statistics of sanctions by type and reasons Are there disciplinary cells? Complaint and inspection procedures Are there complaint and inspection procedures for the detention centre or facility? If so, describe. Describe the independence of those procedures. Accessibility of the procedures. Do guards wear identification badges? Separation of detainees Are men separated from women? Are families provided separate accommodation? Are separated or unaccompanied minors provided separate accommodation? Material Conditions Capacity and occupancy of the detention centre or facility Number of detainees by nationality, age and gender What is the approved capacity of the facility? Accommodations/Cells What is the size and occupancy of the cells or units where detainees sleep? Material conditions: lighting, ventilation, furniture, sanitary facilities Hygiene conditions Food Meals (quality, quantity, frequency) Special dietary regimes (for medical, cultural or religious reasons)
9 Personal hygiene Showers (number, cleanliness, state of repair, frequency for access by detainees, etc.) Sanitary facilities (inside cells, outside, access, cleanliness) Bedding (quality, cleanliness, frequency of change) Possibility of access to laundry facilities Detention Regime and Activities Medical Services Administration of Time Time spent inside unit or cells daily Time spent in daily exercise Time spent daily working Time spent in sports Time spent in other activities Activities offered Work: Is there access to work? Type of work? Renumeration for work? Description of the work. Education: Access to studies by adults and children? Types of studies offered (literacy, primary school, high school, language classes, vocational, university studies). Description of facilities used to provide education in the centre. Leisure: Types of leisure activities, access, description of leisure rooms and sports facilities. Access to library. Religious activities: Access by religious representatives (imam, priest, pastor, etc.). Conditions of access, frequency and duration of visits. Access to religious services and access to a facility to practice. Opportunity to follow religious practices such as washing and diet. Contacts with outside world Visits: access, frequency, conditions for having visits, duration of visits, who can visit, description of visiting rooms. Correspondence and parcels: frequency, censorship, procedures for sending correspondence and letters. Telephone access: frequency, payment for costs. Access to medical care Medical examination upon entry: what type of examination? Who does the examination? Option to request female nurses or doctors. Procedure for accessing medical care while in detention. Medical Infirmary: number of beds, equipment, medication, personnel. Psychological care: Access to psychologists or psychiatrists. Frequency of access. Description of care or services provided. Special care for torture survivors, children, women or elderly. Medical staff: number and availability of doctors, nurses, psychologists and psychiatrists. Prison Staff Number of staff by categories Type of staff: military, police or civilian? Relationship between guards and detainees; relationship between management and the detainees. Training of staff (basic initial training and on-going training).