Telephone Befriending Service

If you have any questions, please do not hesitate to contact our team by phone on 0808 801 0301

Telephone Befriending Form in PDF

Consent for referral(Required)

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

Client Details

Name(Required)

First Last

Mobile Number(Required)

Postcode(Required)

Date of Birth

Please note date format dd/mm/yyyy

Marital Status

Sexual Orientation

Gender

Immigration Status/ Citizenship

Employment Status

Receipt of benefits

Yes

Children

Religion

Key Service Criteria

Any BME / Muslim woman in Scotland for whom all three of the following apply

Feels lonely
Lacks a local social support network
Has access to a telephone line and is comfortable having 30 minute conversations on the phone

Circumstances we need to be aware of

Does the person you are referring have any of the following:

Tick all that apply. This may present a challenge to the provision of Call in Time service. We retain the right not to provide the service in cases where we consider that the service will not be able to meet peoples’ needs.

Diagnosed major depression or anxiety, short memory loss or dementia

Hearing Impairment

If you ticked any of the above, please provide further details:

Please give any further relevant supporting information regarding this referral

(e.g dealing with life changes, loss of family connections, recently moved home, recent return from hospital, other professionals involved). Please provide as much information as possible, including an ideal time to call:

Language Needs:

If your client requires a befriender 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)

Next of Kin (if known)

Name

telephone

relationship

GP name

GP telephone number

GP address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Referrer Details

Referrer Name

First Last

Referrer Job Title

Referrer Organisation

Referrer Contact details

(please provide either a direct line telephone number or an email address that we can contact you on)

How did you hear about Amina Telephone Befriending?

Date(Required)

Consent(Required)

The above referred person agrees to the privacy policy.

I agree to the privacy policy.

Donate

Telephone Befriending Service

Client Details

Key Service Criteria

Circumstances we need to be aware of

Referrer Details

Helpline: 0808 801 0301

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