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Ummer Gatuadress Telefonnummer Postnummer Ort Mobilnummer 2. Beskriv dina besvär mm: 3. Aktuell livssituation inklusive familjeförhållanden: 4. Eventuella tidigare traumatiska upplevelser: 5. Frågeställning / Begäran: 6. Vilka vårdkontakter har du? (exempelvis vårdcentral, specialkliniker/centrum) Vilka läkemedel använder du? 7. Om annan fyller i blanketten: Är personen medveten om att remiss skrivits? Ja Behövs tolk? Ja Nej Nej Språk: [Välj önskat språk eller skri.
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