Request Advice Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Are you requesting advice for yourself or someone else? *I am completing this form for myself or on behalf of a friend or family memberI am a professional referring a clientPlease select from one of the options belowI am the client. I am completing this form myself and would like you to contact me directly to answer my query / offer me an appointment.I am NOT the client. I am completing this form on their behalf and the client would like you to contact me directly to answer the query / book an appointmentI am NOT the client. I am completing this form on their behalf and the client would like you to contact them directly to answer the query / book an appointment.I understand that my personal information will be stored and used in accordance with Citizens Advice Hull and East Riding’s Data Protection and Privacy Policy *YesIf you do not give us permission for us to store your details we will not be able to accept this referral. Without your permission we cannot store your phone number or email address to contact you to book an appointment or answer any advice queries that you have. Please click here to view the Citizens Advice Hull and East Riding Data Protection and Privacy Policy: https://www.hullandeastridingcab.org.uk/disclaimer-copyright-privacy/ If you do not wish to consent to us storing your details by using this form you can contact us on the telephone for advice or visit one of our offices. Please note that the help and assistance we can give may be limited if you do not consent to your details being recorded if you speak to an advisor on the telephone or visit one of our offices. Our contact details and opening times are here: https://www.hullandeastridingcab.org.uk/contact-us/ Please tick here to confirm that the person you are referring has given their permission for this referral. If you do not have consent please obtain it before submitting the referral *YesPlease tick here to confirm that the person you are referring has given their permission for us to store their details. If they have not given consent for their details to be stored we are unable to accept the referral. *YesPlease click here to view the Citizens Advice Hull and East Riding Data Protection and Privacy Policy: https://www.hullandeastridingcab.org.uk/disclaimer-copyright-privacy/ We can only accept referrals for clients who live in Hull or the East Riding of Yorkshire. Please select the area where the client lives: *East Riding of YorkshireKingston Upon HullNeither of theseWe can only accept referrals for clients who live in Hull or the East Riding of Yorkshire. Please select the area where you live. *East Riding of YorkshireKingston Upon HullNeither of theseWe can only accept referrals for people that live in and pay their Council Tax to East Riding of Yorkshire Council and Hull City Council. People that live in other areas can find their closest office and / or details of how to contact Citizens Advice for help via telephone or webchat: https://www.citizensadvice.org.uk/about-us/contact-us/contact-us/contact-us/ Please select the type of organisation that you work for *Charity, Community or Voluntary GroupLocal AuthorityHealth ProfessionalHousing AssociationVeteran Support organisationOtherPlease select your organisation *Age UKBritish Red CrossChild DynamixCarers Support ServiceCherry Tree Advice CentreDoorstepEmmausFoodbankForumFreedom CentreGoodwin CentreGroundworksHCASHessle Road NetworkHEY MindHomestartHU4 Community TrustHull SistersHumbercareP.A.U.L For Brain RecoveryPreston Road Womens CentreProbeRenewSight SupportShores - WithernseaThe HingeThe WarrenTimebankTogether WomenUnity in The CommunityWomen's AidOtherWhich Local Authority do you work for? *East Riding of YorkshireKingston Upon HullWhich area do you work in? *Adult Social ServicesChildrens Social ServicesCustomer Service Team and CentreHousing TeamYour Money TeamOtherPlease select your health professional role *GP PracticeMental Health Service ProfessionalDrug & Alcohol Services (ER Partnership)NHS Your Health Community Link WorkerOtherWhich area do you work in? *Adult Social ServicesCustomer Service Team and CentreEarly Help, Children and Family ServicesHousing TeamOtherIs your GP Practice based in the East Riding or Hull? *East RidingHullPlease select the practice you work in *Alexandra Health Care Centre, 61 Alexandra Road, Hull, HU5 2NTThe Avenues Medical Centre, 147-153 Chanterlands Avenue, Kingston Upon Hull, North Humberside, HU5 3TJThe Bridge Group Practice Elliott Chappell Health Centre, 215 Hessle Raod, Hull, HU3 4BBThe Bridge Group Practice The Orchard Centre, 210 Orchard Park Road, Hull, North Humberside, HU6 9BXBurnbrae Medical Practice 445 Holderness Road, Hull, North Humberside, HU8 8JSCampus Health Centre Newland Health Centre, 187 Cottingham Road, Hull, HU5 2EGCity Health Practice Ltd 225 New Bridge Road, Hull, North Humberside, HU9 2LRClifton House Medical Centre 263-265 Beverley Road, Hull, North Humberside, HU5 2STDELTA Healthcare Park Primary Health Care Centre, 700 Holderness Road, Hull, North Humberside, HU9 3JADiadem Medical Practice Bilton Grange Health Centre, 2 Diadem Grove, Hull, HU9 4ALDr Gt Hendow's Practice Bransholme South Hth Ctr, Goodhart Rd, Bransholme, Kingston-upon-Hull, Hull, North Humberside, HU7 4DWDr Jad Weir & Partners Marfleet Group Practice, Marfleet PCC, Preston Road, Hull, North Humberside, HU9 5HHDrs Raut and Thoufeeq Highlands Health Centre, Lothian Way, Bransholme, Hull, North Humberside, HU7 5DDEast Hull Family Practice 81 Southbridge Road, Victoria Dock, Hull, East Riding Of Yorkshire, HU9 1TREast Hull Family Practice Longhill Health Centre, Shannon Road, Hull, HU8 9RWEast Park Practice Wilberforce Health Centre, 2Nd Floor, 6-10 Storey Street, Hull, HU1 3SAGoodheart Surgery Bransholme Health Centre, Goodhart Road, Bransholme, Hull, North Humberside, HU7 4DWHaxby Orchard Park Surgery 210 Orchard Park Road, Hull, East Riding Of Yorkshire, HU6 9BXHastings Medical Centre 919 Spring Bank West, Hull, HU5 5BEHull Family Practice Morrill Street Health Centre, Morrill Street, Holderness Road, Hull, North Humberside, HU9 2LJJames Alexander Family Practice Bransholme Health Centre, Goodhart Road, Bransholme, Hull, North Humberside, HU7 4DWKingston Health (Wheeler Street, Hull, North Humberside, HU3 5QEMarfleet Group Practice Hauxwell Grove, Middlesex Road, Hull, HU8 0RBNew Hall Surgery, Oakfield Court, Cottingham Road, Hull, Yorkshire, HU6 8QFNewington Health Centre Plane Street, Hull, North Humberside, HU3 6BXOrchard 2000 Group - Bransholme South Health Centre, Goodhart Road, Bransholme, Hull, East Riding Of Yorkshire, HU7 4DWThe Oaks Medical Centre, Council Avenue, Hull, North Humberside, HU4 6RFPark Health Centre 700 Holderness Road, Hull, North Humberside, HU9 3JAPrinces Medical Centre Princes Court, Princes Avenue, Hull, HU5 3QASt Andrews Surgery Elliot Chappell Health Centre, 215 Hessle Road, Hull, North Humberside, HU3 4BBSutton Park Medical Practice Littondale, Sutton Park, Hull, East Riding Of Yorkshire, HU7 4BJWest Hull Health Hub 61 Calvert Lane, Hull, HU4 6BLWilberforce Surgery 1St Floor Wilberfoce Health Centre, 6-10 Story Street, Hull, North Humberside, HU1 3SAWolseley Medical Centre Londesborough Street, Hull, North Humberside, HU3 1DSOther - Not ListedPlease select the practice you work in *Anlaby Surgery Haltemprice Leisure Centre Springfield Way HU10 6QHBartholomew Medical Group Goole Health Centre Woodland Avenue Goole DN14 6RUThe Beverley Health Centre Manor Road Beverley HU17 7BZThe Chestnuts Surgery 45 Thwaite Street Cottingham HU16 4QXChurch View Surgery Market Hill Hedon HU12 8JEEastgate Medical Group 37 Eastgate Hornsea HU18 1LPField House Surgery 18 Victoria Road Bridlington YO15 2ATGilberdyke Health Centre The Health Centre Thornton Dam Lane HU15 2ULGreengates Medical Group 30 Lockwood Road Beverley HU17 9GQThe Hallgate Surgery 123 Hallgate Cottingham HU16 4DAHedon Group Practice Market Hill House 4 Market Hill Hedon HU12 8JDThe Hessle Grange Medical Practice 11 Hull Road Hessle HU13 9LZHowden Medical Centre Pinfold Street Howden DN14 7DDLeven and Beeford Medical Practice 29 High Stile Leven HU17 5NLManor House Surgery Providence Place Bridlington YO15 2QWMarket Weighton Practice 10 Medforth Street Market Weighton YO43 3FFThe Medical Centre Cranwell Road Driffield YO25 6UHMontague Medical Practice Fifth Avenue Goole DN14 6JDNorth Beverley Medical Centre Pighill Lane Woodhall Way Beverley HU17 7JYThe Old Fire Station Albert Terrace Beverley HU17 8JWThe Park Surgery 6 Eastgate North Driffield YO25 6EBPark View Surgery 87 Beverley Road Hessle HU13 9AJPeeler House Surgery 1 Ferriby Road Hessle HU13 0RGPractice 1 The Medical Centre Station Avenue Bridlington YO16 4LZPractice 3 The Medical Centre Station Avenue Bridlington YO16 4LZThe Ridings Medical Group 4 Centurion Way Brough HU15 1AYSnaith and Rawcliffe Medical Group The Marshes Butt Lane Snaith Goole DN14 9DYSouth Holderness Medical Practice St Nicholas Surgery Queen Street Withernsea HU19 2PZWolds View Primary Care Centre Entrance A Bridlington District Hospital Bessingby Road Bridlington YO16 4QPOther - Not ListedPlease specify the surgery you work in *What is your role? *GPSocial PrescriberOtherWhich housing association do you work for *Home GroupHull Church HousesPlaces for PeopleRiversideSanctuaryThirteen GroupOtherPlease select the Veterans Support Association that you work for *Catterick GarrisonCat ZeroThird ChoiceDST LeconfieldGoodwin Development TrustHull 4 HeroesNautilis FundProject NovaRoyal British LegionSeafarersSSAFAVeterans Work ClubOtherPlease select the organisation that you work for *DWPProbationWitness ServiceOtherPlease list your organisation *Please list your team *Please list your job role *Your full name *If there is an issue with the referral you submit eg: a digit is missed from the client's mobile number or we need to clarify something we you we will contact you. Our preferred method of contact is email as we will not necessarily know which days you are working or whether any phone number you list is a direct number or shared with other members of your team Please list your contact number *Please list your email address *EmailConfirm EmailThe following profile questions will all concern the client and the issue(s) that you are referring them for. Please answer them regarding the client - not about yourself Please confirm that you have read and understood the instruction above.YesWe need your consent to record and use your special category personal data Some information about you is called Special Category Data. Please provide any special category data that you consent to us holding. If you do not consent to us storing this information please select "Prefer Not to Say". We need consent to record and use your client’s special category personal data. Some information is called Special Category Data. Please provide any special category data that your client consents to us holding. If they do not consent to us storing this information, please select "Prefer Not to Say" and please do not include any information that contains special category data. Why do we ask this? Funders will often ask what sort of people are using (or not using) our services. Your information allows us to report which groups of people use our services the most and the least. This can help us when we are submitting bids for funding. We will never release your personal information to any Funder. All information listed in funding bids is in number and percentage terms only Ethnicity *White - BritishWhite - EnglishWhite - ScottishWhite - WelshWhite - Northern IrishWhite - IrishWhite - Gypsy or Irish TravellerWhite - OtherMixed - White & Black CaribbeanMixed - White & Black AfricanMixed - White & AsianMixed - OtherAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - OtherAsian or Black British - AfricanAsian or Black British - CaribbeanAsian or Black British - OtherOther - ArabOther - Any OtherUnknownPrefer Not To SayHealth condition(s) *NoneLong TermDisabledUnknownPrefer Not To SayPlease select the relevent long term health issue(s)DeafDexterity eg: lifting or carrying objects, using a keyboardHard of hearingLearning or understanding or concentratingMemoryMental healthMobility eg: Walking short distances or climbing stairsPhysical impairment (non-sensory)Social or behavioural (Autism, ADHD etc)Speech impairmentStamina or breathing or fatigueVisual impairmentOther disability or type not givenSexual orientation *BisexualGay ManGay Woman / LesbianHeterosexual / StraightPrefer Not To SayTrade union membership *Member Of A Trade UnionNot A Member Of A Trade UnionPrefer Not To SayReligion *No ReligionChristian (Any denomination)Christian - CatholicChristian - ProtestantBuddhistHinduJewishMuslimSikhAny Other ReligionPrefer Not To SayI confirm that the client is happy to be contacted for the purpose of collecting feedback on our service *YesNoPlease select the method(s) the client is happy for us to contact them by to ask for feedback on our serviceEmailLetterTextCan we contact you for feedback on the service you have received from us? *YesNoPlease select the method(s) you are happy for us to contact you by to ask for feedback on our serviceEmailLetterTextYour DetailsYou have stated that you are filling in the form on behalf of someone else and that they would like us to contact you or offer you an appointment to deal with the query that relates to them. The next section will ask about you so that we know how to contact you.Please tick to confirm that you have read and understood the above instructionYesYour Name *FirstLastAddress (including postcode)Please select how you would like us to contact you to answer the query / arrange an appointment. *PhonePhone - can leave voicemailEmailLetterPhone *Email *EmailConfirm EmailDo you require an interpreter?YesNoState which language you require *Do you have any communication needs?YesNoState what your communication needs are *Do you have any mobility issues?YesNoState what your mobility needs are *Please check your contact details and confirm that they are correctYesClient detailsThe following questions relate to the client and the issue(s) that they need advice forYour detailsThe following questions relate to you and the issue(s) that you need advice forName *FirstLastGenderMaleFemaleOther (Prefer to use a different team)Prefer not to sayDate of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address (including postcode). Please state No Fixed Abode if you do not currently have an address. * We will be unable to assist a client with advice or contact them to book an appointment if they do not consent to them being contacted by one of the methods listed below. For quickness and efficiency our preferred methods are phone / text / voicemail or email. If a client is generally available we can book them an appointment and send them an appointment letter without talking to them but dealing with an advice issue by letter only is not generally practical. Please confirm that the client is happy to be contacted by any of the following to answer their query / book an appointment: *by phonea voicemail message can be leftby emailby postWe will need to contact you to answer your advice query or to book you an appointment to see an advisor. Please select which of the methods below you would be happy for us to use to contact you *PhonecallLeaving a voicemailSending a text messageEmailPhone *Email *EmailConfirm EmailHas the client, or a member of their household, ever served in the armed forces? *YesNoPrefer Not To SayIf we book an appointment for you will the client be attending with you? *Yes / Don't KnowNoDoes the client need an interpreter? *YesNoState which language is required *Does the client have any communication needs?* *YesNoPlease state what the client's communication needs are *Does the client have any mobility needs? *YesNoPlease state what the client's mobility needs are *Which area is the client's GP Surgery in? *BeverleyBridlingtonGooleHullOther East RidingPrefer Not To SayClient is not registered with a surgeryDon't knowPlease select the client's Beverley SurgeryThe Beverley Health Centre Manor Road Beverley HU17 7BZGreengates Medical Group 30 Lockwood Road Beverley HU17 9GQNorth Beverley Medical Centre Pighill Lane Woodhall Way Beverley HU17 7JYThe Old Fire Station Albert Terrace Beverley HU17 8JWPlease select the client's Bridlington Surgery *Field House Surgery 18 Victoria Road Bridlington YO15 2ATManor House Surgery Providence Place Bridlington YO15 2QWPractice 1 The Medical Centre Station Avenue Bridlington YO16 4LZPractice 3 The Medical Centre Station Avenue Bridlington YO16 4LZWolds View Primary Care Centre Entrance A Bridlington District Hospital Bessingby Road Bridlington YO16 4QPPlease select the client's Goole Surgery *Bartholomew Medical Group Goole Health Centre Woodland Avenue Goole DN14 6RUMontague Medical Practice Fifth Avenue Goole DN14 6JDSnaith and Rawcliffe Medical Group The Marshes Butt Lane Snaith Goole DN14 9DYPlease select the surgery that the client attends *Anlaby Surgery Haltemprice Leisure Centre Springfield Way HU10 6QHThe Chestnuts Surgery 45 Thwaite Street Cottingham HU16 4QXChurch View Surgery Market Hill Hedon HU12 8JEEastgate Medical Group 37 Eastgate Hornsea HU18 1LPGilberdyke Health Centre The Health Centre Thornton Dam Lane HU15 2ULThe Hallgate Surgery 123 Hallgate Cottingham HU16 4DAHedon Group Practice Market Hill House 4 Market Hill Hedon HU12 8JDThe Hessle Grange Medical Practice 11 Hull Road Hessle HU13 9LZHowden Medical Centre Pinfold Street Howden DN14 7DDLeven and Beeford Medical Practice 29 High Stile Leven HU17 5NLMarket Weighton Practice 10 Medforth Street Market Weighton YO43 3FFThe Medical Centre Cranwell Road Driffield YO25 6UHThe Park Surgery 6 Eastgate North Driffield YO25 6EBPark View Surgery 87 Beverley Road Hessle HU13 9AJPeeler House Surgery 1 Ferriby Road Hessle HU13 0RGThe Ridings Medical Group 4 Centurion Way Brough HU15 1AYSouth Holderness Medical Practice St Nicholas Surgery Queen Street Withernsea HU19 2PZOther - Not ListedPlease select the surgery that the client attendsAlexandra Health Care Centre, 61 Alexandra Road, Hull, HU5 2NTThe Avenues Medical Centre, 147-153 Chanterlands Avenue, Kingston Upon Hull, North Humberside, HU5 3TJThe Bridge Group Practice Elliott Chappell Health Centre, 215 Hessle Raod, Hull, HU3 4BBThe Bridge Group Practice The Orchard Centre, 210 Orchard Park Road, Hull, North Humberside, HU6 9BXBurnbrae Medical Practice 445 Holderness Road, Hull, North Humberside, HU8 8JSCampus Health Centre Newland Health Centre, 187 Cottingham Road, Hull, HU5 2EGCity Health Practice Ltd 225 New Bridge Road, Hull, North Humberside, HU9 2LRClifton House Medical Centre 263-265 Beverley Road, Hull, North Humberside, HU5 2STDELTA Healthcare Park Primary Health Care Centre, 700 Holderness Road, Hull, North Humberside, HU9 3JADiadem Medical Practice Bilton Grange Health Centre, 2 Diadem Grove, Hull, HU9 4ALDr Gt Hendow's Practice Bransholme South Hth Ctr, Goodhart Rd, Bransholme, Kingston-upon-Hull, Hull, North Humberside, HU7 4DWDr Jad Weir & Partners Marfleet Group Practice, Marfleet PCC, Preston Road, Hull, North Humberside, HU9 5HHDrs Raut and Thoufeeq Highlands Health Centre, Lothian Way, Bransholme, Hull, North Humberside, HU7 5DDEast Hull Family Practice 81 Southbridge Road, Victoria Dock, Hull, East Riding Of Yorkshire, HU9 1TREast Hull Family Practice Longhill Health Centre, Shannon Road, Hull, HU8 9RWEast Park Practice Wilberforce Health Centre, 2Nd Floor, 6-10 Storey Street, Hull, HU1 3SAHaxby Orchard Park Surgery 210 Orchard Park Road, Hull, East Riding Of Yorkshire, HU6 9BXHastings Medical Centre 919 Spring Bank West, Hull, HU5 5BEHull Family Practice Morrill Street Health Centre, Morrill Street, Holderness Road, Hull, North Humberside, HU9 2LJJames Alexander Family Practice Bransholme Health Centre, Goodhart Road, Bransholme, Hull, North Humberside, HU7 4DWKingston Health (Wheeler Street, Hull, North Humberside, HU3 5QEMarfleet Group Practice Hauxwell Grove, Middlesex Road, Hull, HU8 0RBNew Hall Surgery, Oakfield Court, Cottingham Road, Hull, Yorkshire, HU6 8QFNewington Health Centre Plane Street, Hull, North Humberside, HU3 6BXOrchard 2000 Group - Bransholme South Health Centre, Goodhart Road, Bransholme, Hull, East Riding Of Yorkshire, HU7 4DWThe Oaks Medical Centre, Council Avenue, Hull, North Humberside, HU4 6RFPark Health Centre 700 Holderness Road, Hull, North Humberside, HU9 3JAPrinces Medical Centre Princes Court, Princes Avenue, Hull, HU5 3QASt Andrews Surgery Elliot Chappell Health Centre, 215 Hessle Road, Hull, North Humberside, HU3 4BBSutton Park Medical Practice Littondale, Sutton Park, Hull, East Riding Of Yorkshire, HU7 4BJWest Hull Health Hub 61 Calvert Lane, Hull, HU4 6BLWilberforce Surgery 1St Floor Wilberfoce Health Centre, 6-10 Story Street, Hull, North Humberside, HU1 3SAWolseley Medical Centre Londesborough Street, Hull, North Humberside, HU3 1DSOther - Not ListedPlease list the surgery that the client attends *What does the client need advice about? Please tick as many options as required *BenefitsA consumer problemDebtsA problem with their energy supplierFamily/relationship issuesHousingImmigration issueA problem at workStruggling to afford billsSomething elseBenefits: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *A Consumer Problem: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *Family / Relationship Issues : Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *A problem with their energy supplier: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *Housing: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *Immigration issue: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *A problem at work: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *Struggling to afford bills: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent *Something else: Please provide brief details of the issue and any action taken so far, including any key dates, emergencies or deadlines. As above please do not provide special category data without the client’s consent. *Do you need an interpreter? *YesNoWhich language do you need? *Do you have any communication needs? *Blind interpreterDeaf interpreterPartially sightedHearing impairedAdvocate (someone to speak on your behalf)OtherI do not have any communication needsPlease specify the communication need not listed *Do you have any mobility needs? *YesNoPlease specify your mobility issue(s) *About the client's queryPlease answer the rest of the questions as if you were the client.Are you a serving or former member of the armed forces? *YesNoWhat do you need advice about? *BenefitsConsumer / I have a problem with something I have boughtDebtFamily / Relationship issuesHousingI am struggling to pay my billsImmigrationA problem at workI need advice about something elseBenefitsIt would be helpful for us to know more about your Benefits query. What do you need advice about? *I want to make a claim for Universal Credit.I have received a managed migrations notice letter and have been given a deadline to claim Universal Credit byI would like to see if there are any benefits I can claimI would like help completing a benefit formI would like help to challenge a benefit decision (e.g. an appeal)I claimed Universal Credit about a month ago but I don’t think my first payment is correctI have another benefits issueHave you received a managed migration notice letter which gives you a deadline to claim Universal credit by? *YesNoWhat is the deadline date stated on your letter? *What is your main source of income? *Are you on any benefits if so what are they and how long have you been on them for? *Do you have no income at all? *YesNoPlease tell us about any benefits you already receive. *Do you have any mobility or care needs? *Please select which form or forms you would like help completing *Attendance AllowanceDisability Living AllowanceWork Capability Form (ESA50)Personal Independence Payment (PIP)Work Capability Form (UC50)Another formPlease state which other form you would like help completing *Please state the date by which the form(s) is / are due back *Please tell us which benefit and any important dates or deadlines. Please tell us if you have already contacted the DWP about the decision. *Other benefit issue: Please tell us about the problem and what you have done so far to try to resolve it. Please tell us if there are any important dates or deadlines. *Consumer / I have a problem with something I have boughtYou can contact the specialist Citizens Advice Consumer Helpline by telephone, webchat or online form if you need more help with a consumer problem. The contact information is available here: https://www.citizensadvice.org.uk/consumer/get-more-help/if-you-need-more-help-about-a-consumer-issue/ If you would like to request consumer advice from Citizens Advice Hull and East Riding please tell us more about the problem below, however, we might need to signpost you to the Consumer Helpline for further advice. Please select one of the following options *I will call the Consumer HelplineI would like help from Citizens AdviceDetails of how to contact our Consumer Service (and other national services) can be found here: https://www.citizensadvice.org.uk/about-us/contact-us/contact-us/contact-us/ What do you need advice about? Please tell us more about the problem, any action you have taken so far and details of any important dates including when you bought the item or paid for the service. *Family and Relationship IssuesPlease read the following carefully. We need to know if there is another person involved in your issue that you may be in disgareement with. This could be your partner if there is disagreement over a divorce or access to children for example. It could be a parent, sibling or other relative if someone has died and you are in disagreement about a will. We call this Conflict of Interest. Citizens Advice needs to know if someone else is involved in your query as we cannot assist both people who are in dispute ie: if you are divorcing your partner we cannot help both you and your partner. We will therefore be asking whether someone else is involved in your issue and, if so, who they are. The information you provide will allow us to check our systems so we can be sure we are not helping you and the person or people you are in disagreement with. Please make sure you have read the above about Conflict of Interest. Is there another person involved in your query that you are in disagreement with? *YesNoPlease give the name of the person you are in disagreement with *FirstLastPlease give their date of birth if you know itPlease give their address and any other information you think is relevant. If you are in disagreement with more then one person please use this box to list any others. *I am married to my partner *YesNoI am experiencing domestic violence or abuse *YesNoWhat do you need advice about? *I would like advice about separating from my partner/spouseI would like advice on child maintenanceI would like regarding access to my child(ren)I would like advice following a deathSomething elsePlease select one of the options *I am being asked to pay child maintenanceI would like advice on how to get child maintenance.Please tell us about the issue and any actions you have taken so far. *Please tell us who has died and what you would like advice about. *Please tell us about the problem and any actions you have taken so far. *HousingWhat do you need advice about? *I have been asked to leave my homeI need help with repairsI have a problem with a neighbourOtherWhen did you move into the property *Please tell us about the problem and what you have done so far to try to resolve it. *Do you owe money to your landlord? *YesNoDo you have a mortgage? *YesNoWhat date have you been asked to leave? *Has there already been a court hearing? *YesNoNot applicableWhen was the court hearing? *Please give details of the court hearing and what the decision was *I am struggling to pay my billsPlease tell us which bills you are struggling to pay *Council TaxEnergy (gas / electricity)Rent/MortgageTV LicenceWaterOtherPlease tell us about the problem with your Council Tax bill and any actions you have taken so far including key dates and any court action *Please tell us about the problem with your rent or mortgage and any actions you have taken so far including key dates and any court action *Please tell us about the problem with your TV Licence and any actions you have taken so far including key dates and any court action *Please tell us about the problem with your water bill and any actions you have taken so far including key dates and any court action *Please tell us about the problem and any actions you have taken so far including key dates and any court action. *It would be helpful for us to know more about your query. Who is your energy supplier? If you have a different supplier for gas and electric please list who supplies your gas and who supplies your electricity. *What is your payment method? E.g. meter top up, direct debit, pay on receipt of bill Do you currently have an energy supply? *YesNoPlease tell us about the problem and any actions you have taken so far including key dates and any court action *ImmigrationUnder Office of the Immigration Services Commissioner (OISC) regulations Citizens Advice Hull and East Riding can give Level 1 immigration advice. This means we might not be able to assist with your immigration enquiry if it is more complex. We will contact you to let you know if we cannot give you advice on your issue. What do you need advice about? *I have a question about the EU Settlement SchemeI have a query about my immigration statusOtherWhat is your status? *SettledPre-settledOtherWhen did you come to the UK? *Please tell us more about your issue, any action you have taken so far and details of any important dates. *What is your status? *Please tell us more about your issue including your current immigration status *Please tell us more about your issue, any action you have taken so far and details of any important dates *A problem at workPlease note: If you provide any information about your trade union membership in this section please make sure you have given us consent to record this earlier in this form. What do you need advice about? *I have been dismissed from my jobI have a problem with my employerOtherHow long have you worked for your employer? *Less than 2 yearsMore than 2 yearsAre you currently off work due to illness? *YesNoAre you a member of a trade union? *YesNoPrefer not to sayPlease tell us the date you were dismissed from your job *Please tell us more about the problem including any action you have taken so far. What outcome would you like? *Please tell us about the problem and what you have done so far to try to resolve it. Please tell us if there are any important dates or deadlines. *Please tell us about the problem and what you have done so far to try to resolve it. Please tell us if there are any important dates or deadlines. *I need advice about something elsePlease tell us more about your issue, any action you have taken so far and details of any important dates. *DebtIt would be helpful for us to know more about your query. Please answer the questions below. Please answer the following questions about debts on behalf of the client. Please select your household type *Single personSingle person with dependant childrenSingle person with non-dependant childrenCoupleCouple with dependant childrenCouple with non-dependant childrenOther adults onlyOther adults with dependant childrenOther adults with non-dependant childrenPrefer not to sayPlease select your housing type *Own outrightBuying home (with mortgage etc)Shared ownershipCouncil / ALMO tenantHousing associationPrivate tenantHoused through jobStaying with relatives/friends (paying rent)Staying with relatives/friends (rent free)HostelPrisonHomeless (inc. b&b tenant),Residential accommodation (care home etc)OtherPrefer not to sayPlease select your employment status *Employed 30 or more hours per week,Employed between 16 and 29 hoursEmployed less than 16 hoursUnemployed – seeking paid employmentVolunteerRetiredSemi-retiredStudentOn Government scheme for employmentCarer for elderly / disabledCarer for childrenLooking after home - No dependentsLooking after home - with dependentsPermanently sick / disabledTemporarily sickSelf employedCasual / seasonal workerOtherPrefer not to sayPlease select your marital status *SingleSeparated but legally married / civil partnershipDivorced / civil partnership dissolvedWidowed / surviving civil partnerMarriedCohabitingCivil partnershipPrefer not to sayHow many people are there in your household? *How many of these are dependents? *012345More Than 5What is the age of dependent #1 *What is the age of dependent #2 *What is the age of dependent #3 *What is the age of dependent #4 *What is the age of dependent #5 *Please list the ages of any other dependents if you have more than 5 *How many vehicles do you have in the household? *Do you have a partner / ex partner who may be receiving debt advice from us? YesNoPlease list the name and address of the partner / ex partner who may be receiving advice from us *Are any of the debt business debts? *NoneDon't knowSomeAllHave you had previous debt advice *No previous adviceDebt Management PlanFormal insolvency solutionTelephone advice eg: National DebtlineOnline - browsing / researchOnline - webchat / emailAdvice from Citizens AdviceOther face to face adviceHave you tried and failed to set up a payment plan, or set up a payment plan but failed to keep up payments? *YesNoPlease tell us what you have tried *Do you have any of the debts listed below? *Mortgage ArrearsRent ArrearsSecured loan arrearsCouncil taxTV licence arrearsHire Purchase (HP) / Conditional SaleGasElectricDual FuelWater ArrearsChild support arrearsMagistrates Court Fine ArrearsNational Insurance Contribution ArrearsIncome Tax ArrearsHMRC Tax Credit OverpaymentBenefit overpayment (not Housing Benefit)Budgeting advance on Universal CreditShort Term Benefits or Universal Credit AdvanceFriends / FamilyFixed Penalty Notice (driving / vehicle related)Fixed Penalty Notice (non driving related)Penalty Notice for Disorder (PND)None of the aboveMortgage arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Mortgage arrears: Please state the monthly repayment amount (if known) *Rent arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Rent arrears: Please state the monthly repayment amount (if known) *Secured loan arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Secured loan arrears: Please state the monthly repayment amount (if known) *Council tax arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Council tax arrears: Please state the monthly repayment amount (if known) *TV licence arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *TV licence arrears: Please state the monthly repayment amount (if known) *Hire purchase (HP) / conditional sale arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Hire purchase (HP) / conditional sale arrears: Please state the monthly repayment amount (if known) *Gas arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Gas arrears: Please state the monthly repayment amount (if known) *Electric arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Electric arrears: Please state the monthly repayment amount (if known) *Dual fuel arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Duel fuel arrears: Please state the monthly repayment amount (if known) *Water arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Water arrears: Please state the monthly repayment amount (if known) *Child support arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Child support arrears: Please state the monthly repayment amount (if known) *Magistrate's court fine arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Magistrate's court fine arrears: Please state the monthly repayment amount (if known) *National Insurance contribution arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *National Insurance contribution arrears: Please state the monthly repayment amount (if known) *Income tax arrears: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Income tax arrears: Please state the monthly repayment amount (if known) *HMRC tax credit overpayment: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *HMRC tax credit overpayment: Please state the monthly repayment amount (if known) *Benefit overpayment (not housing benefit): Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Benefit overpayment (not housing benefit): Please state the monthly repayment amount (if known) *Budgeting advance on Universal Credit: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Budgeting advance on Universal Credit: Please state the monthly repayment amount (if known) *Short term benefits or Universal Credit advance: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Short term benefits or Universal Credit advance: Please state the monthly repayment amount (if known) *Friends / Family: Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Friends / Family: Please state the monthly repayment amount (if known) *Fixed Penalty Notice (driving / vehicle related): Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Fixed Penalty Notice (driving / vehicle related): Please state the monthly repayment amount (if known) *Fixed Penalty Notice (non driving related): Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Fixed Penalty Notice (non driving related): Please state the monthly repayment amount (if known) *Penalty Notice for Disorder (PND): Please state the total amount owed. Please enter 0.01 if you have arrears but don't know or can't estimate the amount owed. *Penalty Notice for Disorder (PND): Please state the monthly repayment amount (if known) *Do you have any other debts? *Yes - and I can provide details of the amounts owedYes - but I can only provide an estimate of the amount owedNoPlease list the companies that you owe money to and the amounts owed *Please list the companies you owe money to and an estimated total. If you're struggling to work out an estimate please use less than eg: less than £10,000 or less than £20,000 etc. If you're not sure of the companies please estimate a total eg: £X owed to 9 companies *Do you have a County Court Judgement, often referred to as a CCJ or a High Court Judgement (HCJ)? *YesNoDo you have any assets eg: property, car, savings. other? *YesNoValue of Properties (less mortgage outstanding) *Value of vehicle(s) (less HP outstanding) – please exclude disability adapted vehicles *Please list the amount of any savings which you have *Please list any other assets and their value *Are you aged 54 or above? *YesNoDo you have a private or company pension? *YesNoIs your private or company pension: *Defined benefit / final salaryDefined contributionWhat is your estimated pension pot? If you do not know please enter 0.01 *Can you provide detailed information about your income and spending? *YesNoWhat is your estimated surplus income (how much money do you have left at the end of each month) *None£75 or lessBetween £75 and £100More than £100Please tell us whether you receive income from any of the following sources and how much your receive. It would be helpful if you list each amount as a montlhly amount. If you are listing an amount over a different time period eg: weekly or fortnightly please list this. your salary or wages (take home) partner's salary or wages (take home) Other earnings (including self employment) Universal Credit Child Benefit Universal Credit housing costs / Housing Benefit Council tax support Personal Independence Payment (PIP) Disability Living Allowance (DLA) Carer's Allowance Statuatory sick pay Employment and Support Allowance Attendance Allowance Child tax credit Guardian's allowance Incapacity benefit Income support Industrial injuries benefit Job seekers allowance Maternity allowance Working tax credit Discretionary Housing Payment (DHP) Other benefits / tax credits State pension(s) Private or work pension(s) Pension credit Other pensions Maintenance or child support Boarders or lodgers Non - dependent contributions Student loans and grants Household contribution from partner Other income Please give details in the box below. Please refer to the box above and list details of your income *Please tell us whether you spend your money on any of the following sources and how much you spend. It would be helpful if you list each amount as a montlhly amount. If you are listing an amount over a different time period eg: weekly or fortnightly please list this. Rent Ground rent and service charges Mortgage Mortgage endowments Secure loans Council rax / rates Applicance and furniture rental (including HP) TV licence Other costs Electricity Gas Other expenditure Other costs (eg coal, oil) Water supply Water waste Childcare costs Adult care costs Child maintenance and support Prescriptions and medicines Dentists and opticians Other health costs Public transport Hire purchase of vehicle Car insurance Road tax MOT and ongoing maintenance Breakdown cover fuel, parking and toll road charges Other (eg taxis) School uniform After school clubs and school trips Other school costs Pension payments Life insurance Mortgage payment protection insurance Building and contents insurance Health insurance Other pension costs Other insurance costs Professional courses Union fees Professonal fees Other professional costs Other essential costs Home phone, internet, TV packages Mobile phone(s) Hobbies, leisure or sport Gym memberships Gifts Pocket money Newspapers and magazines Other leisure costs Groceries Nappies and baby items School meals and meal at work Laundry and dry cleaning Alcohol Smoking products Vets bills and pet insurance House repairs and maintenance Other food and housekeeping costs Clothing and footwear Hairdressing Toiletries Other personal costs Monthly saving amount Please give details in the box below. Please refer to the box above and list details of your spending. *Is this an emergency? *YesNoWhat kind of emergency is it? *Eviction - I have an eviction notice to leave the property onBailiff's visitingNo money for food or heatingHaving gas, water or electricity disconnectedI have a statutory demand or creditor's petition for bankruptcy and need to respondCourt appearance - I need to attend for a possesion hearingMoney taken directly from bank accountArrestOther - I have a committal warning for non payment of council tax and need to respond byOther – I have another urgent matter (please give details)Please list any key dates eg: date you have to leave the property on if being evicted, date of court appearance or date you need to respond to the statutory demand or committal warning by *Are you confident dealing with letters and forms in your day-to-day life? *YesNoDo you have internet access and are you happy using it on your own? *YesNoDo you feel that you have been discriminated against in one or more of the areas below? *AgeDisabiltyGender reassignmentMarriage or civil partnership (in employment only)Pregnancy and maternityRaceReligion and beliefSexSexual orientationNo - I don't feel I have been discriminated againstPlease give details of the discrimination *NextPlease confirm that you are ready to submit your responses *SubmitBackSubmit Download QR 🡻