Make a Referral – Request Advice for Someone Else If you would like to request advice from Citizens Advice, you will need to answer these questions first. Hull and East Riding Citizens Advice provide this service. We will treat all personal information as confidential and details will not be shared without consent, unless we are required to do so by Law. The information provided here will be used to make appointments only. If you wish to know more about our Data Protection and Privacy policy, please click here Are you requesting advice for a client or someone else?YesNo If you are requesting advice for yourself please use our personal form here We need your consent and that of your client to use some information, including ethnicity, religion, health conditions, sexual orientation and trade union membership. If you agree, we will use this information, which is known as 'special category personal data'. ***If you do not wish for us to store this information for use in both monitoring and in relation to your enquiry, please do not provide it*** Before you continue, please confirm that you have the consent of the person you are referring for Hull and East Riding Citizens Advice to store the details of the person you are referring:YesNo We need your consent to record and use your special category personal data Special Category Information Please provide any special category data that they consent to us holding. If they do not consent to us storing their special category data, please select "Prefer Not to Say" Gender?—Please choose an option—FemaleMaleUnknownTransgender male-femaleTransgender female-malePrefers different term Ethnicity?—Please choose an option—Prefer Not to SayWhite - 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 - OtherBlack or Black British - AfricanBlack or Black British - CaribbeanBlack or Black British - OtherOther - ArabOther - Any OtherUnknown Health Conditions —Please choose an option—Prefer Not to SayLong TermDisabledMental HealthPhysical Impairment (non-sensory)Visual ImpairmentSpeech ImpairmentHard of HearingDeafLearning DisabilityCognitive ImpairmentMultiple ImpairmentsOther Disability or Type not given Trade Union Membership —Please choose an option—Prefer Not to SayYesNo Accessing our service Do they need an interpreter?YesNo If yes, what language do they need? The following 2 questions are asking for their special category data. Please ensure you have given us permission to store this in the section above. Do they have any communication needs? Do they have any mobility needs? Personal Details Their first name Their surname Date of Birth Do they live in Hull or East Riding Council Areas?HullEast Riding Do they have a registered home address?YesNo Their address Postcode Telephone number Email address Their GP Surgery—Please choose an option—CHCP – City CentreCHCP – East Park Park Health CentreCHP Ltd – BransholmeCHP Ltd – Southcoates & MarfleetClifton House Medical CentreDelta HealthcareDr GT HendowEast Hull Family PracticeField View SurgeryGoodheart SurgeryHastings MedicalHaxby – Burnbrae SurgeryHaxby – Calvert & NewingtonHaxby – Kingswood & Orchard ParkJames Alexander PracticeKingston HealthLaurbel SurgeryMarfleet Group PracticeModality HullNewland Health CentreNorthpointOrchard 2000Princes MedicalRaut PartnershipSt Andrews Group PracticeSutton Manor SurgerySydenham House Group PracticeThe Avenues Medical CentreThe Bridge GroupThe Oaks Medical CentreWilberforce SurgeryWolseley Medical CentreAnlaby SurgeryBeverley - Greengates Medical GroupBeverley - Manor Road SurgeryBeverley - North Beverley Medical CentreBeverley - The Old Fire Station SurgeryBridlington - Field House SurgeryBridlington - Manor House SurgeryBridlington - Practice OneBridlington - Practice TwoBridlington - Practice ThreeBridlington - Wolds View SurgeryBrough - The Ridings Medical GroupCottingham - King Street Medical CentreDriffield - The Medical CentreDriffield - The Park SurgeryEastgate Medical GroupGoole - Bartholomew Medical GroupGoole - Montague Medical PracticeGilberdyke Health CentreHessle - Park View SurgeryHessle Grange Medical PracticeH.O.S.M - The Ridings Medical GroupHowden Medical PracticeHolderness HealthLeven and Beeford Medical PracticeMarket Weighton PracticeNorth Ferriby SurgerySnaith and Rawcliffe Medical GroupSouth cave - The Ridings Medical GroupWillerby and Swanland SurgeryUnknown/Prefer Not To Say Are they a serving or former member of the armed forces?—Please choose an option—YesNo Armed Forces Details Are they...? A Military SpouseCurrently servingRetiredA dependant of a serving member of the military or a veteran In which service did they serve? Royal Air ForceBritish ArmyRoyal NavyReservist What is their service number? What is/was their period of service? From: To: Were they medically discharged? YesNo Are they in receipt of...? War PensionArmed Forces Compensation PaymentsPersonal Independence PaymentsCarers AllowanceAFPS 75/05/15 Pension Do we have permission to contact them via phoneYesNo Do we have permission to contact them via emailYesNo Do we have permission to contact them via letterYesNo Do we have permission to contact them via textYesNo Do we have permission to contact them via voicemailYesNo Main Reason for Referral Please tell us the reason they require support. (please select one option only)—Please choose an option—BenefitsHousingEnergy - Supplier IssuesDebtRelationship breakdown/familyEmploymentOther-(Utilities, immigration, consumer or other legal matters) What is their household situation? Live AloneCoupleLive with childrenShared propertyNone of the above How many bedrooms does their home have? What is their employment status? WorkingNot WorkingRetired How are they housed? Owned OutrightBuying with the mortgagePrivate rentedCouncil rentedHousing associatonLiving with family or friendsHomeless Have they been issued with... Any notice seeking possessionNotice of court proceedingsWarrant for possession Do they have any assets? i.e. a car, savings, house, motorcycle? Roughly, what is their total monthly income Do they have more or less than £75 spare monthly income, after all of normal expenses were met?MoreLess Roughly, what is their total amount of debt? Do they have any of these priority debts? Rent/mortgage arrearsGas/electricityCouncil taxMagistrate's FineHire purchaseNone of these debts Are you aware of any of the following urgent actions being taken against them? Possession or EvictionBailiffsDisconnection of fuel supplyCommittalStatutory demand for bankruptcyNone of these actions Please tell us about their issue. Please provide as much detail as possible in the text box below Do any of the below apply to them? They are being evicted/or losing their homeThey have to appear in CourtThey have an urgent deadline (e.g. from the DWP)No urgent issue Referrer Contact Details Referrer Name Referrer Email Address Referrer Phone Number Are you..? CABCharity, Community or Voluntary GroupsFriend/Family/CarerGP PracticeHealth ProfessionalSocial ServicesStatutoryLegal ProfessionalLocal AuthorityOther Are you from..?GAUMAPSBBOHTCPensionwiseArmed ForcesEnergy TeamOther What is your organisation?> —Please choose an option—Age UKBritish Red CrossChild DynamixCredit UnionCarers Support ServiceCherry Tree Advice CentreCVSEmmausERVASFishermans MissionFreedom CentreFoodbankForumGroundworksGoodwin CentreHCASHEY MindHomestartHull DAPHull SistersP.A.U.L for Brain RecoveryPreston Road Women’s CentreProbeRenewRBLSSAFASight SupportShores Centre - WithernseaTarget HousingTogether WomenTimebankThe HingeThe WarrenUnity in the Community You are a...?FamilyFriendUnpaid CarerProfessional Carer/Support Worker Relationship to the person you are referring? Your Practice?—Please choose an option—CHCP – City CentreCHCP – East Park Park Health CentreCHP Ltd – BransholmeCHP Ltd – Southcoates & MarfleetClifton House Medical CentreDelta HealthcareDr GT HendowEast Hull Family PracticeField View SurgeryGoodheart SurgeryHastings MedicalHaxby – Burnbrae SurgeryHaxby – Calvert & NewingtonHaxby – Kingswood & Orchard ParkJames Alexander PracticeKingston HealthLaurbel SurgeryMarfleet Group PracticeModality HullNewland Health CentreNorthpointOrchard 2000Princes MedicalRaut PartnershipSt Andrews Group PracticeSutton Manor SurgerySydenham House Group PracticeThe Avenues Medical CentreThe Bridge GroupThe Oaks Medical CentreWilberforce SurgeryWolseley Medical CentreAnlaby SurgeryBeverley - Greengates Medical GroupBeverley - Manor Road SurgeryBeverley - North Beverley Medical CentreBeverley - The Old Fire Station SurgeryBridlington - Field House SurgeryBridlington - Manor House SurgeryBridlington - Practice OneBridlington - Practice TwoBridlington - Practice ThreeBridlington - Wolds View SurgeryBrough - The Ridings Medical GroupCottingham - King Street Medical CentreDriffield - The Medical CentreDriffield - The Park SurgeryEastgate Medical GroupGoole - Bartholomew Medical GroupGoole - Montague Medical PracticeGilberdyke Health CentreHessle - Park View SurgeryHessle Grange Medical PracticeH.O.S.M - The Ridings Medical GroupHowden Medical PracticeHolderness HealthLeven and Beeford Medical PracticeMarket Weighton PracticeNorth Ferriby SurgerySnaith and Rawcliffe Medical GroupSouth cave - The Ridings Medical GroupWillerby and Swanland SurgeryUnknown/Prefer Not To Say You are a...?Acute Service Health ProfessionalMental Health Service ProfessionalCommunity Health Service Professional Your Organisation? Your Role/Team? You work from:HRIICCNeither Please select:See and SolveLocality TeamsActive RecoveryLong Term ConditionsSensory TeamSafeguarding TeamOther Your Role/Team? Please select:Police ServiceFire ServiceDWPCourtsProbationOther Your Role/Team? Please select:Hull City CouncilEast riding of Yorkshire Council Your Role/Team? Feedback Can we contact you for your feedback on our service?—Please choose an option—YesNo If so, can we contact you via: PhoneEmailLetter
