Sahara Scotland Casework Referral Sahara Scotland Self Referral Form Client (Your) DetailsName(Required) First Last Email(Required) Mobile Number(Required)It is safe to contact you: It is safe to contact me It is safe to text me It is safe to leave a voicemail Postcode(Required)Date of BirthPlease note date format dd/mm/yyyy DD slash MM slash YYYY What is your ethnicity?(Required)Afghani, Afghani Scottish or Afghani BritishAfrican, African Scottish or African BritishArab, Arab Scottish or Arab BritishBangladeshi, Bangladeshi Scottish or Bangladeshi BritishBlack, Black Scottish or Black BritishCaribbean, Caribbean Scottish or Caribbean BritishChinese, Chinese Scottish or Chinese BritishIndian, Indian Scottish or Indian BritishIraqi, Iraqi Scottish or Iraqi BritishPakistani, Pakistani Scottish or Pakistani BritishWhite - Scottish, British, Irish, Romany, Polish or OtherOtherImmigration Status/ Citizenship(Required)Other informationKey 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. Please provide as much information as possible including details of:(Required)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.)Language Needs:(Required)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)How did you hear about caseworker service?Date(Required) DD slash MM slash YYYY Consent(Required) I agree to the privacy policy. Δ
