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CICA New Client Questionnaire

Please provide as much information as you have available. We will work off the papers as far as we possibly can.

Client's full name
Any previous names
Address
Telephone Number
Email address (if contactable by email)
Contact details of referral agency (name and email address)
Date of Birth
National Insurance Number (if available)
Nationality
Town/place of birth
Gender* / Male/Female
Occupation (prior to incident)
Date of trafficking to the UK
Date of escape from trafficking situation
Do you have a positive NRM decision? (ie have you been identified as a victim of trafficking by the UK authorities?) / YES / NO
PLEASE PROVIDE COPIES OF ANY PAPERWORK
Locations where exploitation took place (addresses if possible)
Names of traffickers and other perpetrators (if known)
Please explain what happened to you in as much detail as possible / PLEASE ALSO PROVIDE COPIES OF ANY WRITTEN DOCUMENTS AVAILABLE (EG WITNESS STATEMENTS, MEDICAL RECORDS, IMMIGRATION DOCUMENTS ETC)
Has the incident been reported to the police? / Yes / No
If yes, please provide date(s): ______
Have the traffickers or other perpetrators been convicted? / Yes / No
If yes, please provide date(s): ______
PLEASE PROVIDE COPIES OF ANY COURT JUDGMENTS (IF YOU HAVE THEM AVAILABLE)
Please provide details of any police contacts involved in the case
Please provide a police reference number (if available)
Please provide details of any other agency involved in the case
Please briefly summarise the injuries suffered
Did you seek medical help for your injuries? / YES / NO
If yes, please provide date(s): ______
If yes, please provide contact details for the hospital / GP:
______
Are you still receiving treatment? / YES / NO
If yes, please provide details:
______
Do you have any physical scars as a result of your injuries? / YES / NO
If yes, please provide details:
______
Do you have any criminal convictions (in the UK, your home country or elsewhere)? / YES / NO
If yes, please provide details:
______
Have you been trafficked before? / YES / NO
If yes, please provide details:
______
Have you made any other claims for compensation in connection with this incident? / YES / NO
If yes, please provide details:
______

LIB01/CM3DA/3285958.1Hogan Lovells