Third Party Casework Referral

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

Consent for referral(Required)

I have authorisation to complete this form on behalf of the person specified:

Client Details

Name(Required)

First Last

Email(Required)

Mobile Number(Required)

Is it safe to contact this person?

It is safe to contact the client

It is safe to text the client

It is safe to leave a voicemail for the client

Postcode(Required)

Date of Birth

Please note date format dd/mm/yyyy

Immigration Status/ Citizenship

Other information

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.

Please provide as much information as possible including details of:

Any support the client is currently receiving. Any further relevant supporting information regarding this referral (including a brief history of the client relevant to the case e.g. any mental health issues, experience of domestic abuse or immigration issues and what support they have received to date.)

Language Needs:

If your client requires 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)