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Imaan Support Hub
To request support through the Imaan Support Hub, please fill in the following form and we will contact you to arrange an appointment.
Imaan Support Hub
Imaan Support Hub
Name
*
First
Last
*
Last
Date of birth:
*
*
*
Gender
*
Gender
Male
Female
Prefer not to say
Phone
*
Email
*
Address
*
Town/City
*
Postcode
*
Emergency contact name & relationship
*
Emergency contact number
*
Reason for Seeking Support
*
Mental Health (stress, anxiety, depression)
Marriage & Relationship Issues
Family Conflicts
Bereavement & Loss
Addiction (substance, gambling, pornography, etc.)
Trauma & Abuse Recovery
Spiritual Struggles & Faith-Based Concerns
Anger Management
Self-Esteem & Confidence Issues
Other (specify below)
Other issues?
Describe the main issue you would like support with:
*
Have you received counselling or support before?
*
Yes
No
If yes, please provide details:
Do you have any medical conditions or take any medications that may affect your wellbeing?
*
Yes
No
If yes, please specify:
Are you currently under the care of a doctor, therapist, or psychiatrist?
*
Yes
No
If yes, please specify:
Do you feel safe at home?
*
Yes
No
Have you ever had thoughts of harming yourself or others?
*
Yes
No
If yes, please explain:
Do you have any history of addiction, self-harm, or suicidal thoughts?
*
Yes
No
If yes, please provide details:
Would you like Islamic/spiritual guidance as part of your support?
*
Yes
No
Are there any specific Islamic concerns related to your issue?
*
Yes
No
If yes, please specify:
Confidentiality & Consent I understand that my information will be kept confidential within Imaan Support Hub, except in cases where there is a risk of harm to myself or others.
*
I agree to receive counselling and understand the confidentiality policy.
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Contact Us
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Foodbank Referral Form
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