Initial Referral Form for Pastoral care & Islamic counselling

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Bismillah Al-Rahman Al-Raheem

We use this form to learn a little about you and the problem you are bringing to our 'Pastoral care or Islamic Counselling' service. Pastoral care involves discussing and giving solutions from an Islamic perspective (i.e. where we can look at the rulings etc.).

We have found it saves a great deal of time when it comes to your first communication with us and prevents us from having to subject you to a stream of questions at a time when perhaps nervousness prevents you from thinking straight!

We have tried to keep things as simple as possible so please answer all questions as fully as possible.

Importance notice:

1. Only complete this form if it about yourself
2. In-person counselling is only provided to individuals residing within Greater London, United Kingdom (within the boundaries of the M25)
3. At busy times we may take up to 10 days to reply back to you due to a high volume of cases
4. If you're enquiry is urgent and you require help immediate, please make sure you make it very clear and the reasons relating to it

Email *

Important notice:

Before going ahead in completing this form, please note we are unable to provide you with the service(s) listed below if they are directly or indirectly linked to any form of legal court proceeding or child custody issues.

I confirm the service(s) I wish to proceed with Al-Madad have no direct or indirect association with any form of legal court proceeding or child custody issues. *

Yes

(FOR INDIVIDUAL COUNSELLING) Which option below best describes the service you are after?

Email response service, £20 per single issue

Phone counselling: first 50-minute session is £40, every subsequent hour is charged at a rate of £35

Face to face counselling: first 50-minute session is £40, every subsequent hour is charged at a rate of £35

Clear selection

(FOR COUPLE COUNSELLING) Which option below best describes the service you are after?

Email response service, £30 per single issue

Phone counselling: first 50-minute session is £90, subsequent hour is charged at a rate of £50

Face to face counselling: first 50-minute session is £90, subsequent hour is charged at a rate of £50

Clear selection

Please select the most suitable option below which applies to you? (Note: The term 'earn enough' also refers to your total family income) *

I earn enough to proceed with with the required 'email response or counselling session'

I don't earn enough to proceed with the required 'email response or counselling session' and require special consideration

Special Consideration: FREE 1 hour counselling by phone only (maximum 1 session)

In respect to taking into account of your 'Special Consideration' please clearly explain your reason?

AL-MADAD OUTREACH COUNSELLING SERVICE OFFERING SCOPE

We are only able to provide you with our services based on the categories listed below. If you're unable to find what you're looking for then unfortunately we are unable to provide you with the necessary support. Email us on support@almadad.org and we maybe able to signpost you to another organisation.

Which category(s) below best describes the issues you are currently facing? *

Muslim marriage Mediation or Counselling

Personal Islamic guidance

Muslim family dispute

Domestic violence and spousal abuse

Cognitive racial bias of gender and race due to trauma and perception issues

Faith crisis

Spiritual Abuse by religious figures

Spiritual Burnout

Fiqh related questions supported by a Fatwa board

Grief counseling

Deindividuation and burnout from groups and sects

Life Coaching

Required

Your Full Name *

Contact number *

Gender *

Male

Female

Required

Please explain the problem you would like us to you help you with? *

What would you like us to do? *

Have you previously attended a 'Counselling' session with Al-Madad Outreach? *

Yes

Required

If you've answered 'Yes' to the above question, please provide us with further information?

Have you previously attended a 'Counselling' session anywhere else? *

Yes

Required

If you've answered 'Yes' to the above question, please provide us with further information?

How did you hear about *

Facebook

Website

Google Search

Word of Mouth

Leaflet

Radio Advertisement

Stall or Exhibition

Service Information

The nature of our service means we are very busy and have limited resources to deal with each and every enquiry coming through our door. For individuals who require special considerations for fee purposes, we will ensure to review this on a case by case basis, taking into consideration an individual's personal circumstances and affordability.

1. A subsidised/discounted price cost structure
2. Affordability of the client
3. Our counselling service scope

Price Structure:

Our assessment and counselling sessions will be either provided by either email, telephone, face-to-face, online video (Whatsapp, Zoom, Skype or Google Hangout) or in-person

Email response service
Single issue - £20.00

Phone Counselling
Individual counselling: first 50-minute session is £40.00, every subsequent hour is charged at a rate of £35.00
Couples counselling: first 50-minute session is £90, subsequent hour is charged at a rate of £50.

In Person Counselling
Individual counselling: first 50 minute session consisting of up to 2 hours charged is at £40, subsequent hour is charged at a rate of £35.
Couples In-Person counselling: first 50 minute session consisting of up to 2 hours charged is at £90, subsequent hour is charged at a rate of £50

Payment will be required in advance before the session starts and a member of the Al-Madad Outreach team will be in contact with you with the payment details.

Out of Hours Counselling & Non-Booked appointment

Upon the discretion of the counsellor and where the counsellor is urgently required in-between your agreed sessions, a flat rate of £60 will be charged per hour.

3. Duration of Counselling session: Sessions duration will last for 1 hour.

Opening Hours for Appointments (subject to availability of our counsellors)

Monday - Friday: between 10am - 10pm
Saturday & Sunday: between 10am - 9pm

We take every effort to keep your data is secure and confidential. We strongly abide by the rules and regulations set out in the Data Protection Act 2018. In the event that you would like a copy of your information held by us, please email support@almadad.org and will endeavour to assist you. (Registration number: ZA749289)

Jazākallahu Khayran,

Al-Madad Community Outreach
M:+44 7946 074 603
T: +44 207 097 5229
support@almadad.org
www.almadad.org
www.patreon.com/almadad

Please be aware that this is not an emergency service. If you feel at all threatened or are in immediate danger, please call the police on 999 or 101.

Please be aware that we have a 10 day turn-around policy whereby we aim to reply to all your enquires, starting with the most urgent.

Thank you for time in completing the form. The next step will be for you to submit the form and a member of our assessment team will be in touch with you within the next 10 working days.

Please note: we are currently experiencing a high volume of enquiries and have a waiting list before we can offer appointments to any new clients. Current waiting period is 16-20 weeks.

Jazak'Allahu Khayran

OFFICE USE ONLY

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