About this Application

This form must be completed by a Health Professional

An Initial Assessment (IA) to access services at Spirasi includes a ‘medical and psychosocial assessment, followed by
a psychotherapeutic assessment if required

Please ensure the form is completed clearly, giving as much information as possible.

Spirasi's remit for IA is based on the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT) definition of torture.

We, therefore, provide services to those whose experiences are encompassed by the following elements of the UNCAT definition:

  • Experience of severe pain or suffering, whether physical or mental where it was:
  • Intentionally inflicted by another person or persons:
  • For specific purposes, namely obtaining information or a confession, or to punish, coerce or intimidate, and this was:
  • Carried out by a state actor or person acting in an official capacity.

In addition, we may accept referrals where there has been serious threat to a civilian’s life or person by reason of indiscriminate violence in situations of international or internal armed conflict.

Spirasi will not be able to see a client unless they are registered with a GP

You must

  • Complete all sections of this application
  • Reply to confirmation email with requested documents


Any queries regarding the online referral process can be submitted to

1 Personal Details
2 Description of case
3 Detention Details
4 Current Situation
5 Referrer Details

Personal Details

All sections must be completed

First name

Last name


Date of birth


Email Address

Telephone Number

Country of origin

Country (other)

Native Language(s)

Marital Status

Number of child dependents outside Ireland

Number of child dependents in Ireland

Is the person a separated child seeking international protection?

Is an interpreter required?

Residency Status

Please fill in all the required fields to continue

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Description of Case

Spirasi is governed by our own remit as set out at the start of the application. The information below is requested to clarify if the application comes within that remit. All sections must be completed.

1. Did the person experience severe pain or suffering, whether physical or mental?

Please detail:

Please check relevant boxes where information is available







Toe/Fingernail Removal

Sexual Assault


Other Pain Experienced


2. Was the torture inflicted for a particular purpose? Please expand i.e. intimidation, confession, information, etc.

3. Who was the perpetrator? i.e government official, police, military, non-stage actors including armed groups, de facto regimes

4. Where did the torture happen? (street, place of detention, prison, unknown)
If in a place of detention please complete the “Detention Details” section in Step 3.

5. When did the torture happen? (date/s or unknown)

Please fill in all the required fields to continue

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Details relating to detention and/or ill-treatment:

Please answer these questions only if you have been detained

1.  Detention in country of origin:
     Arrested and/or detained?


2.  When did this occur?

3.  For how long?

4.  Country where this occured

Country (other)

5.  Facility where this occured

6.  Why was the client detained, and by whom?

Please fill in all the required fields to continue

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Current Situation

All sections must be completed

1.  Please provide details of the current psychological and physical symptoms of the client:

2.  Please provide details of any treatment currently or previously provided to the client in Ireland:

3.  Please list any current medications

4.  In what way do you think Spirasi may be able to assist your client? i.e psychotherapy, family therapy, group therapy, LGBTQ support, psychosocial support, befriending, English language support

Please fill in all the required fields to continue

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Referrer Details

All sections must be completed

First name:

Last name:


Referrer Type


Email Address

Telephone Number

Please fill in all the required fields to continue

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Spirasi uses your personal data (such as your contact details) in order support the administration of our organisation including the provision of our services and information about those services. For further information on how we use your personal data, please see our privacy notice.