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 DetailsName(Required) First Last Email Mobile Number(Required) Postcode(Required) Date of BirthPlease note date format dd/mm/yyyy DD slash MM slash YYYY Marital Status Sexual Orientation Gender Immigration Status/ Citizenship Employment Status Receipt of benefits Yes No 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 ofDoes 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)Nametelephonerelationship Add RemoveGP name GP telephone number GP address Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Referrer DetailsReferrer 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) DD slash MM slash YYYY Consent(Required) The above referred person agrees to the privacy policy. I agree to the privacy policy. Δ