Helpline 1

Casework Self Referral

If you have any questions, please do not hesitate to contact our team by phone on 0141 212 8420

Are you completing this form for someone else? Please use the third party referral form.

Casework self referral in PDF

Client (Your) Details

Name(Required)

It is safe to contact you:

Please note date format dd/mm/yyyy
DD slash MM slash YYYY

Key Service Criteria

To provide one to one confidential support, advocacy, assistance, and information to any BME / Muslim woman in Scotland for whom any three of the following apply:

  • experiencing or at risk of domestic abuse.
  • women experiencing poor or worsening mental health.
  • women with insecure immigration status and no recourse to public funds.

Any support you are currently receiving from other organisations. Any further relevant supporting information regarding this referral (including a brief history of any mental health issues, experience of domestic abuse or immigration issues and what support you have received to date.)

If you require a worker who speaks a language other than English, please specify here: (* Please note, while Amina volunteers speak a range of community languages, we may not be able to accommodate all requests)

DD slash MM slash YYYY
Consent(Required)