Documentation Intake Form

This information is used only to connect you with the right support and is kept strictly confidential. Requesting: Medical Support.

I am the victim

Reporting my own experience

Reporting on behalf of the victim

You're helping someone else report

Your details

Full name

Telephone

County

Age

Gender

Location

Details of violation

Date of violation

Time of violation

Location

County

Description

Method of torture (select all that apply)

Beating Waterboarding Psychological abuse Sexual violence Denial of food/water Other

Case type

New case Follow-up case

I consent to Independent Medico Legal Unit processing this information for the purpose of providing support and case follow-up, in line with their confidentiality policy.

Documentation Intake Form

Your details

Victim's details

Details of violation