Across Ummah

Mental Health & Wellness
Community Projects
Workshops & Training
Youth
Empowerment
About Us

Mental Health & Awareness
Community Projects
Worshops & Training
Youth
Empowerment
About Us

Across Ummah Counselling / Therapy Referral form

First Name

Middle Name

Last Name

Date of Birth

Sex

Marital Status

Phone Number

Do you give permission for voicemails to be left on your telephone?

Do you give permission for voicemails to be left on your mobile phone?

Do you give permission to receive text message reminders prior to your appointments?

Is an interpreter required?

If yes, please state the language required

When is the best time to contact you?

How did you hear about Across Ummah?

Who is making the referrals?

Referrer Name

Referrer Email

Referrer Contact Number

Referrer Organisation

Common life problems

Parental Problems

Relationship

Lifestyle Problems

Drinking

Weight

Smoking

Stress

Gambling

Common mental health problems

Parental Problems

Relationship

Generalized Anxiety Disorder

Panic Disorder

Suicidal Ideation

Hoarding

Loneliness

Menopausal

Self Esteem

Self Harm

Trauma

Attention Deficit/Hyperactivity Disorder (ADHD)

Complex Mental Health Problems

Schizophrenia

Psychosis

Post-Traumatic Stress Disorder (PTSD)

Bipolar

Obsessive-compulsive disorder (OCD)

Phobias

Substance Disorder

Eating Disorders

Paranoia

Personality Disorders

Mood Disorders

Hearing Voices

Seasonal Affective Disorder (SAD)

Complex relationship issues

I confirm I have the consent of the individual/family referred above

Make a Donation

Support a movement aimed at building a better future for all while addressing the pressing issues within our society.

Account Information

Name:

Across Ummah

Bank:

Cashplus Bank

Number:

06479412

Sort Code:

08-71-99

If you have any questions or need assistance, please contact us at admin@acrossummah.com

Topics

Mental Health

Community Projects

Workshops and Training

Address

Piccadilly
Business Centre
Aldow Enterprise
Park Manchester,
M12 6AE, UK

Contact

+44(0)7747 129530

admin@acrossummah.com

Others

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