MLR Referral Form banner

About this Application

This form must be completed by a solicitor for Medico-Legal Assessment ONLY. Initial Assessment application forms to
access broader Spirasi services are available here.

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.

On an exceptional basis, and within our context as a non-governmental organisation with limited resources, we may
consider MLR referrals which encapsulate ‘serious harm’ as defined by the Qualification Directive
(Directive 2011/95/EU) and related jurisprudence. The limits of our remit mean that we cannot accept referrals in
relation to violence of a primarily domestic or familial nature, or where the violence inflicted is of a strictly criminal
classification.*

We are receiving such a high volume of referrals for MLRs that currently we are only able to accept applications at appeal stage, unless there are particular extenuating circumstances.

In view of this, please answer the questions in this application as precisely as possible:

 

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 referralquery@spirasi.ie

START
1 Personal Details
2 Description of case
3 Detention Details
4 Physical Impact
5 Medical Professional(s)
6 Legal Representation

Personal Details

All sections must be completed

First name

Last name

Address

Date of birth

Gender
  
  
      

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
  
  
      

International Protection Application Reference Number

Legal Aid Board Reference Number

Please fill in all the required fields to continue

Go back Continue to Step 2

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. Does the client claim torture, inhumane or degrading treatment in their country of origin?

  
  

Has the client disclosed this in their International Protection Questionnaire?

  
  
  

Has the client disclosed this at the IPO Substantive Interview?

  
  

2. Did the person experience severe pain or suffering, whether physical or mental?
Please detail:

Please check relevant boxes where information is available

Beating

Kicking

Cuts

Burns

Suspensions

Submersion

Toe/Fingernail Removal

Sexual Assault

Rape

Other

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

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

5.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.

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

Please fill in all the required fields to continue

Go back Continue to Step 3

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. What was the duration?

4. Country where this occured

5. Facility where this occured

6. Why was the client detained?

Please fill in all the required fields to continue

Go back Continue to Step 4

Physical and Psychological Impact

All sections must be completed

1. Please list physical evidence of injuries stated by client or observed

2. Current physical/psychological symptoms reported by the client:

Does the client suffer from

Headaches

Chronic Pains

Nightmares

Suicide Ideations

Appetite Problems

Behavioural Problems

Acute Anxiety

Depression

Flashbacks

Insomnia

Other

3. Did the client receive medical treatment in relation to the violence perpetrated prior to arrival in Ireland?
If so, please detail.

4. Please detail any treatment currently or previously provided in Ireland in relation to the violence perpetrated.

5. Please list the client’s current medication.

6. Please refer to the MLR guidance note for details of topics typically covered by Spirasi MLRs. Please indicate if there is a particular issue which you would like to be included and we will consider this in our preparation of the report.

Please fill in all the required fields to continue

Go back Continue to Step 5

Medical Professional(s)

All sections must be completed

1. GP

First name

Last name

Organisation

Address

Email Address

Telephone Number


2. Other ( Please complete as relevant )

Job title

First name

Last name

Organisation

Address

Email Address

Telephone Number

Please fill in all the required fields to continue

Go back Continue to Step 6

Legal Representation

All sections must be completed

1. Solicitor

First name:

Last name:

Company name:

Address

Email Address

Telephone Number

2. Caseworker ( Please complete as relevant )

First name:

Last name:

Email Address

Telephone Number

Please fill in all the required fields to continue

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X

MLR Referral Form

Has the report been requested by the International Protection Office or the International Protection Appeals Tribunal by a particular date?

  
  

If yes, please enter date

Please leave any additional comments to your application below

Please fill in all the required fields to continue

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