Request Advice Form

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- Step 1 of 2

Are you requesting advice for yourself or someone else? *

I am completing this form for myself or on behalf of a friend or family member
I am a professional referring a client

Please select from one of the options below

I 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 appointment
I 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 *

If 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 *

Please 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. *

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/

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 Yorkshire
Kingston Upon Hull
Neither of these

We 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 Yorkshire
Kingston Upon Hull
Neither of these

We 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 Group
Local Authority
Health Professional
Housing Association
Veteran Support organisation
Other

Please select your organisation *

Age UK
British Red Cross
Child Dynamix
Carers Support Service
Cherry Tree Advice Centre
Doorstep
Emmaus
Foodbank
Forum
Freedom Centre
Goodwin Centre
Groundworks
HCAS
Hessle Road Network
HEY Mind
Homestart
HU4 Community Trust
Hull Sisters
Humbercare
P.A.U.L For Brain Recovery
Preston Road Womens Centre
Probe
Renew
Sight Support
Shores - Withernsea
The Hinge
The Warren
Timebank
Together Women
Unity in The Community
Women's Aid
Other

Which Local Authority do you work for? *

East Riding of Yorkshire
Kingston Upon Hull

Which area do you work in? *

Adult Social Services
Childrens Social Services
Customer Service Team and Centre
Housing Team
Your Money Team
Other

Please select your health professional role *

GP Practice
Mental Health Service Professional
Drug & Alcohol Services (ER Partnership)
NHS Your Health Community Link Worker
Other

Which area do you work in? *

Adult Social Services
Customer Service Team and Centre
Early Help, Children and Family Services
Housing Team
Other

Is your GP Practice based in the East Riding or Hull? *

East Riding
Hull

Please select the practice you work in *

Alexandra Health Care Centre, 61 Alexandra Road, Hull, HU5 2NT
The Avenues Medical Centre, 147-153 Chanterlands Avenue, Kingston Upon Hull, North Humberside, HU5 3TJ
The Bridge Group Practice Elliott Chappell Health Centre, 215 Hessle Raod, Hull, HU3 4BB
The Bridge Group Practice The Orchard Centre, 210 Orchard Park Road, Hull, North Humberside, HU6 9BX
Burnbrae Medical Practice 445 Holderness Road, Hull, North Humberside, HU8 8JS
Campus Health Centre Newland Health Centre, 187 Cottingham Road, Hull, HU5 2EG
City Health Practice Ltd 225 New Bridge Road, Hull, North Humberside, HU9 2LR
Clifton House Medical Centre 263-265 Beverley Road, Hull, North Humberside, HU5 2ST
DELTA Healthcare Park Primary Health Care Centre, 700 Holderness Road, Hull, North Humberside, HU9 3JA
Diadem Medical Practice Bilton Grange Health Centre, 2 Diadem Grove, Hull, HU9 4AL
Dr Gt Hendow's Practice Bransholme South Hth Ctr, Goodhart Rd, Bransholme, Kingston-upon-Hull, Hull, North Humberside, HU7 4DW
Dr Jad Weir & Partners Marfleet Group Practice, Marfleet PCC, Preston Road, Hull, North Humberside, HU9 5HH
Drs Raut and Thoufeeq Highlands Health Centre, Lothian Way, Bransholme, Hull, North Humberside, HU7 5DD
East Hull Family Practice 81 Southbridge Road, Victoria Dock, Hull, East Riding Of Yorkshire, HU9 1TR
East Hull Family Practice Longhill Health Centre, Shannon Road, Hull, HU8 9RW
East Park Practice Wilberforce Health Centre, 2Nd Floor, 6-10 Storey Street, Hull, HU1 3SA
Goodheart Surgery Bransholme Health Centre, Goodhart Road, Bransholme, Hull, North Humberside, HU7 4DW
Haxby Orchard Park Surgery 210 Orchard Park Road, Hull, East Riding Of Yorkshire, HU6 9BX
Hastings Medical Centre 919 Spring Bank West, Hull, HU5 5BE
Hull Family Practice Morrill Street Health Centre, Morrill Street, Holderness Road, Hull, North Humberside, HU9 2LJ
James Alexander Family Practice Bransholme Health Centre, Goodhart Road, Bransholme, Hull, North Humberside, HU7 4DW
Kingston Health (Wheeler Street, Hull, North Humberside, HU3 5QE
Marfleet Group Practice Hauxwell Grove, Middlesex Road, Hull, HU8 0RB
New Hall Surgery, Oakfield Court, Cottingham Road, Hull, Yorkshire, HU6 8QF
Newington Health Centre Plane Street, Hull, North Humberside, HU3 6BX
Orchard 2000 Group - Bransholme South Health Centre, Goodhart Road, Bransholme, Hull, East Riding Of Yorkshire, HU7 4DW
The Oaks Medical Centre, Council Avenue, Hull, North Humberside, HU4 6RF
Park Health Centre 700 Holderness Road, Hull, North Humberside, HU9 3JA
Princes Medical Centre Princes Court, Princes Avenue, Hull, HU5 3QA
St Andrews Surgery Elliot Chappell Health Centre, 215 Hessle Road, Hull, North Humberside, HU3 4BB
Sutton Park Medical Practice Littondale, Sutton Park, Hull, East Riding Of Yorkshire, HU7 4BJ
West Hull Health Hub 61 Calvert Lane, Hull, HU4 6BL
Wilberforce Surgery 1St Floor Wilberfoce Health Centre, 6-10 Story Street, Hull, North Humberside, HU1 3SA
Wolseley Medical Centre Londesborough Street, Hull, North Humberside, HU3 1DS
Other - Not Listed

Please select the practice you work in *

Anlaby Surgery Haltemprice Leisure Centre Springfield Way HU10 6QH
Bartholomew Medical Group Goole Health Centre Woodland Avenue Goole DN14 6RU
The Beverley Health Centre Manor Road Beverley HU17 7BZ
The Chestnuts Surgery 45 Thwaite Street Cottingham HU16 4QX
Church View Surgery Market Hill Hedon HU12 8JE
Eastgate Medical Group 37 Eastgate Hornsea HU18 1LP
Field House Surgery 18 Victoria Road Bridlington YO15 2AT
Gilberdyke Health Centre The Health Centre Thornton Dam Lane HU15 2UL
Greengates Medical Group 30 Lockwood Road Beverley HU17 9GQ
The Hallgate Surgery 123 Hallgate Cottingham HU16 4DA
Hedon Group Practice Market Hill House 4 Market Hill Hedon HU12 8JD
The Hessle Grange Medical Practice 11 Hull Road Hessle HU13 9LZ
Howden Medical Centre Pinfold Street Howden DN14 7DD
Leven and Beeford Medical Practice 29 High Stile Leven HU17 5NL
Manor House Surgery Providence Place Bridlington YO15 2QW
Market Weighton Practice 10 Medforth Street Market Weighton YO43 3FF
The Medical Centre Cranwell Road Driffield YO25 6UH
Montague Medical Practice Fifth Avenue Goole DN14 6JD
North Beverley Medical Centre Pighill Lane Woodhall Way Beverley HU17 7JY
The Old Fire Station Albert Terrace Beverley HU17 8JW
The Park Surgery 6 Eastgate North Driffield YO25 6EB
Park View Surgery 87 Beverley Road Hessle HU13 9AJ
Peeler House Surgery 1 Ferriby Road Hessle HU13 0RG
Practice 1 The Medical Centre Station Avenue Bridlington YO16 4LZ
Practice 3 The Medical Centre Station Avenue Bridlington YO16 4LZ
The Ridings Medical Group 4 Centurion Way Brough HU15 1AY
Snaith and Rawcliffe Medical Group The Marshes Butt Lane Snaith Goole DN14 9DY
South Holderness Medical Practice St Nicholas Surgery Queen Street Withernsea HU19 2PZ
Wolds View Primary Care Centre Entrance A Bridlington District Hospital Bessingby Road Bridlington YO16 4QP
Other - Not Listed

Please specify the surgery you work in *

What is your role? *

GP
Social Prescriber
Other

Which housing association do you work for *

Home Group
Hull Church Houses
Places for People
Riverside
Sanctuary
Thirteen Group
Other

Please select the Veterans Support Association that you work for *

Catterick Garrison
Cat Zero
Third Choice
DST Leconfield
Goodwin Development Trust
Hull 4 Heroes
Nautilis Fund
Project Nova
Royal British Legion
Seafarers
SSAFA
Veterans Work Club
Other

Please select the organisation that you work for *

DWP
Probation
Witness Service
Other

Please 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 *

Confirm Email

The 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.

We need your permission to record and use your personal data

Please answer the questions below. If you do not consent to us storing this information please select "Prefer Not to Say".

We need permission to record and use your client’s special personal data.

Please provide any 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 their 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 - British
White - English
White - Scottish
White - Welsh
White - Northern Irish
White - Irish
White - Gypsy or Irish Traveller
White - Other
Mixed - White & Black Caribbean
Mixed - White & Black African
Mixed - White & Asian
Mixed - Other
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Other
Asian or Black British - African
Asian or Black British - Caribbean
Asian or Black British - Other
Other - Arab
Other - Any Other
Unknown
Prefer Not To Say

Health condition(s) *

None
Long Term
Disabled
Unknown
Prefer Not To Say

Please select the relevent long term health issue(s)

Deaf
Dexterity eg: lifting or carrying objects, using a keyboard
Hard of hearing
Learning or understanding or concentrating
Memory
Mental health
Mobility eg: Walking short distances or climbing stairs
Physical impairment (non-sensory)
Social or behavioural (Autism, ADHD etc)
Speech impairment
Stamina or breathing or fatigue
Visual impairment
Other disability or type not given

Sexual orientation *

Bisexual
Gay Man
Gay Woman / Lesbian
Heterosexual / Straight
Prefer Not To Say

Religion *

No Religion
Christian (Any denomination)
Christian - Catholic
Christian - Protestant
Buddhist
Hindu
Jewish
Muslim
Sikh
Any Other Religion
Prefer Not To Say

I confirm that the client is happy to be contacted for the purpose of collecting feedback on our service *

Please select the method(s) the client is happy for us to contact them by to ask for feedback on our service

Email
Letter
Text

Can we contact you for feedback on the service you have received from us? *

Please select the method(s) you are happy for us to contact you by to ask for feedback on our service

Email
Letter
Text

Your Details

You 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 instruction

Your Name *

First

Last

Address (including postcode)

We may be able to answer your query without booking you an appointment. Which method would you prefer for us to communicate with you by? *

Email (please note email is suitable only for one - off simple queries. It should not be used if you may wish to ask additional questions)
Phone

If you have not answered when we've called to give you advice we may wish to let you know we'll call again. How would you like us to do this? *

Leave me a voicemail
Send me a text
Send me an email

We may need to book an appointment with you. How would you like us to do this? *

Email me an appointment - I'm available most of the time
Text me an appointment - I'm available most of the time
Send me an appointment letter - I'm available most of the time
Ring me - I need to know what days and times are available

Phone *

Email *

Confirm Email

Do you require an interpreter?

State which language you require *

Do you have any communication needs?

State what your communication needs are *

Do you have any mobility issues?

State what your mobility needs are *

Please check your contact details and confirm that they are correct

Client details

The following questions relate to the client and the issue(s) that they need advice for

Your details

The following questions relate to you and the issue(s) that you need advice for

Name *

First

Last

Gender

Male
Female
Other (Prefer to use a different team)
Prefer not to say

Date of birth *

Address (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 some queries we can offer advice via email or phone. Phone is advised for more complex issues or if there may be any additional questions the client might want to ask our advisor. Email is generally only practical for simple questions that do not require an ongoing conversation.

If a client is generally available we can book them an appointment and send them an appointment letter, email or text without talking to them. If a client is only available on certain days or times then it is advisable for them to talk to our admin team and to agree a suitable appointment time with them.

We may be able to answer your query without booking you an appointment. Which method would you prefer for us to communicate with you by? *

Email
Phone

If you have not answered when we've called to give you advice we may wish to let you know we'll call again. How would you like us to do this? *

Leave me a voicemail
Send me a text
Send me an email

We may need to book an appointment with you. How would you like us to do this? *

Email me an appointment - I'm available most of the time
Text me an appointment - I'm available most of the time
Send me an appointment letter - I'm available most of the time
Ring me - I need to know what days and times are available

We may be able to answer your query without booking you an appointment. Which method would you prefer for us to communicate with you by? *

Email
Phone

If you have not answered when we've called to give you advice we may wish to let you know we'll call again. How would you like us to do this? *

Leave me a voicemail
Send me a text
Send me an email

We may need to book an appointment with you. How would you like us to do this? *

Email me an appointment - I'm available most of the time
Text me an appointment - I'm available most of the time
Send me an appointment letter - I'm available most of the time
Ring me - I need to know what days and times are available

Phone *

Email *

Confirm Email

Has the client, or a member of their household, ever served in the armed forces? *

Yes
No
Prefer Not To Say

If we book an appointment for you will the client be attending with you? *

Yes / Don't Know
No

Does the client need an interpreter? *

State which language is required *

Does the client have any communication needs?* *

Please state what the client's communication needs are *

Does the client have any mobility needs? *

Please state what the client's mobility needs are *

Which area is the client's GP Surgery in? *

Beverley
Bridlington
Goole
Hull
Other East Riding
Prefer Not To Say
Client is not registered with a surgery
Don't know

Please select the client's Beverley Surgery

The Beverley Health Centre Manor Road Beverley HU17 7BZ
Greengates Medical Group 30 Lockwood Road Beverley HU17 9GQ
North Beverley Medical Centre Pighill Lane Woodhall Way Beverley HU17 7JY
The Old Fire Station Albert Terrace Beverley HU17 8JW

Please select the client's Bridlington Surgery *

Field House Surgery 18 Victoria Road Bridlington YO15 2AT
Manor House Surgery Providence Place Bridlington YO15 2QW
Practice 1 The Medical Centre Station Avenue Bridlington YO16 4LZ
Practice 3 The Medical Centre Station Avenue Bridlington YO16 4LZ
Wolds View Primary Care Centre Entrance A Bridlington District Hospital Bessingby Road Bridlington YO16 4QP

Please select the client's Goole Surgery *

Bartholomew Medical Group Goole Health Centre Woodland Avenue Goole DN14 6RU
Montague Medical Practice Fifth Avenue Goole DN14 6JD
Snaith and Rawcliffe Medical Group The Marshes Butt Lane Snaith Goole DN14 9DY

Please select the surgery that the client attends *

Anlaby Surgery Haltemprice Leisure Centre Springfield Way HU10 6QH
The Chestnuts Surgery 45 Thwaite Street Cottingham HU16 4QX
Church View Surgery Market Hill Hedon HU12 8JE
Eastgate Medical Group 37 Eastgate Hornsea HU18 1LP
Gilberdyke Health Centre The Health Centre Thornton Dam Lane HU15 2UL
The Hallgate Surgery 123 Hallgate Cottingham HU16 4DA
Hedon Group Practice Market Hill House 4 Market Hill Hedon HU12 8JD
The Hessle Grange Medical Practice 11 Hull Road Hessle HU13 9LZ
Howden Medical Centre Pinfold Street Howden DN14 7DD
Leven and Beeford Medical Practice 29 High Stile Leven HU17 5NL
Market Weighton Practice 10 Medforth Street Market Weighton YO43 3FF
The Medical Centre Cranwell Road Driffield YO25 6UH
The Park Surgery 6 Eastgate North Driffield YO25 6EB
Park View Surgery 87 Beverley Road Hessle HU13 9AJ
Peeler House Surgery 1 Ferriby Road Hessle HU13 0RG
The Ridings Medical Group 4 Centurion Way Brough HU15 1AY
South Holderness Medical Practice St Nicholas Surgery Queen Street Withernsea HU19 2PZ
Other - Not Listed

Please select the surgery that the client attends

Alexandra Health Care Centre, 61 Alexandra Road, Hull, HU5 2NT
The Avenues Medical Centre, 147-153 Chanterlands Avenue, Kingston Upon Hull, North Humberside, HU5 3TJ
The Bridge Group Practice Elliott Chappell Health Centre, 215 Hessle Raod, Hull, HU3 4BB
The Bridge Group Practice The Orchard Centre, 210 Orchard Park Road, Hull, North Humberside, HU6 9BX
Burnbrae Medical Practice 445 Holderness Road, Hull, North Humberside, HU8 8JS
Campus Health Centre Newland Health Centre, 187 Cottingham Road, Hull, HU5 2EG
City Health Practice Ltd 225 New Bridge Road, Hull, North Humberside, HU9 2LR
Clifton House Medical Centre 263-265 Beverley Road, Hull, North Humberside, HU5 2ST
DELTA Healthcare Park Primary Health Care Centre, 700 Holderness Road, Hull, North Humberside, HU9 3JA
Diadem Medical Practice Bilton Grange Health Centre, 2 Diadem Grove, Hull, HU9 4AL
Dr Gt Hendow's Practice Bransholme South Hth Ctr, Goodhart Rd, Bransholme, Kingston-upon-Hull, Hull, North Humberside, HU7 4DW
Dr Jad Weir & Partners Marfleet Group Practice, Marfleet PCC, Preston Road, Hull, North Humberside, HU9 5HH
Drs Raut and Thoufeeq Highlands Health Centre, Lothian Way, Bransholme, Hull, North Humberside, HU7 5DD
East Hull Family Practice 81 Southbridge Road, Victoria Dock, Hull, East Riding Of Yorkshire, HU9 1TR
East Hull Family Practice Longhill Health Centre, Shannon Road, Hull, HU8 9RW
East Park Practice Wilberforce Health Centre, 2Nd Floor, 6-10 Storey Street, Hull, HU1 3SA
Haxby Orchard Park Surgery 210 Orchard Park Road, Hull, East Riding Of Yorkshire, HU6 9BX
Hastings Medical Centre 919 Spring Bank West, Hull, HU5 5BE
Hull Family Practice Morrill Street Health Centre, Morrill Street, Holderness Road, Hull, North Humberside, HU9 2LJ
James Alexander Family Practice Bransholme Health Centre, Goodhart Road, Bransholme, Hull, North Humberside, HU7 4DW
Kingston Health (Wheeler Street, Hull, North Humberside, HU3 5QE
Marfleet Group Practice Hauxwell Grove, Middlesex Road, Hull, HU8 0RB
New Hall Surgery, Oakfield Court, Cottingham Road, Hull, Yorkshire, HU6 8QF
Newington Health Centre Plane Street, Hull, North Humberside, HU3 6BX
Orchard 2000 Group - Bransholme South Health Centre, Goodhart Road, Bransholme, Hull, East Riding Of Yorkshire, HU7 4DW
The Oaks Medical Centre, Council Avenue, Hull, North Humberside, HU4 6RF
Park Health Centre 700 Holderness Road, Hull, North Humberside, HU9 3JA
Princes Medical Centre Princes Court, Princes Avenue, Hull, HU5 3QA
St Andrews Surgery Elliot Chappell Health Centre, 215 Hessle Road, Hull, North Humberside, HU3 4BB
Sutton Park Medical Practice Littondale, Sutton Park, Hull, East Riding Of Yorkshire, HU7 4BJ
West Hull Health Hub 61 Calvert Lane, Hull, HU4 6BL
Wilberforce Surgery 1St Floor Wilberfoce Health Centre, 6-10 Story Street, Hull, North Humberside, HU1 3SA
Wolseley Medical Centre Londesborough Street, Hull, North Humberside, HU3 1DS
Other - Not Listed

Please list the surgery that the client attends *

What does the client need advice about? Please tick as many options as required *

Benefits
A consumer problem
Debts
A problem with their energy supplier
Family/relationship issues
Housing
Immigration issue
A problem at work
Struggling to afford bills
Something else

Benefits: 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? *

Which language do you need? *

Do you have any communication needs? *

Blind interpreter
Deaf interpreter
Partially sighted
Hearing impaired
Advocate (someone to speak on your behalf)
Other
I do not have any communication needs

Please specify the communication need not listed *

Do you have any mobility needs? *

Please specify your mobility issue(s) *

About the client's query

Please answer the rest of the questions as if you were the client.

Are you a serving or former member of the armed forces? *

What do you need advice about? *

Benefits
Consumer / I have a problem with something I have bought
Debt
Family / Relationship issues
Housing
I am struggling to pay my bills
Immigration
A problem at work
I need advice about something else

Benefits

It 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 by
I would like to see if there are any benefits I can claim
I would like help completing a benefit form
I 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 correct
I have another benefits issue

Have you received a managed migration notice letter which gives you a deadline to claim Universal credit by? *

What 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? *

Please 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 Allowance
Disability Living Allowance
Work Capability Form (ESA50)
Personal Independence Payment (PIP)
Work Capability Form (UC50)
Another form

Please 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 bought

You 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 Helpline
I would like help from Citizens Advice

Details 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 Issues

Please 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? *

Please give the name of the person you are in disagreement with *

First

Last

Please give their date of birth if you know it

Please 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 *

I am experiencing domestic violence or abuse *

What do you need advice about? *

I would like advice about separating from my partner/spouse
I would like advice on child maintenance
I would like regarding access to my child(ren)
I would like advice following a death
Something else

Please select one of the options *

I am being asked to pay child maintenance
I 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. *

Housing

What do you need advice about? *

I have been asked to leave my home
I need help with repairs
I have a problem with a neighbour
Other

When 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? *

Do you have a mortgage? *

What date have you been asked to leave? *

Has there already been a court hearing? *

Yes
No
Not applicable

When was the court hearing? *

Please give details of the court hearing and what the decision was *

I am struggling to pay my bills

Please tell us which bills you are struggling to pay *

Council Tax
Energy (gas / electricity)
Rent/Mortgage
TV Licence
Water
Other

Please 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? *

Please tell us about the problem and any actions you have taken so far including key dates and any court action *

Immigration

Under Office of the Immigration Advice Authority (IAA) 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 Scheme
I have a query about my immigration status
Other

What is your status? *

Settled
Pre-settled
Other

When 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 work

Please 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 job
I have a problem with my employer
Other

How long have you worked for your employer? *

Less than 2 years
More than 2 years

Are you currently off work due to illness? *

Are you a member of a trade union? *

Yes
No
Prefer not to say

Please 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. *

I need advice about something else

Please tell us more about your issue, any action you have taken so far and details of any important dates. *

Debt

It 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 person
Single person with dependant children
Single person with non-dependant children
Couple
Couple with dependant children
Couple with non-dependant children
Other adults only
Other adults with dependant children
Other adults with non-dependant children
Prefer not to say

Please select your housing type *

Own outright
Buying home (with mortgage etc)
Shared ownership
Council / ALMO tenant
Housing association
Private tenant
Housed through job
Staying with relatives/friends (paying rent)
Staying with relatives/friends (rent free)
Hostel
Prison
Homeless (inc. b&b tenant),
Residential accommodation (care home etc)
Other
Prefer not to say

Please select your employment status *

Employed 30 or more hours per week,
Employed between 16 and 29 hours
Employed less than 16 hours
Unemployed – seeking paid employment
Volunteer
Retired
Semi-retired
Student
On Government scheme for employment
Carer for elderly / disabled
Carer for children
Looking after home - No dependents
Looking after home - with dependents
Permanently sick / disabled
Temporarily sick
Self employed
Casual / seasonal worker
Other
Prefer not to say

Please select your marital status *

Single
Separated but legally married / civil partnership
Divorced / civil partnership dissolved
Widowed / surviving civil partner
Married
Cohabiting
Civil partnership
Prefer not to say

How many people are there in your household? *

How many of these are dependents? *

0
1
2
3
4
5
More Than 5

What 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?

Please list the name and address of the partner / ex partner who may be receiving advice from us *

Are any of the debt business debts? *

None
Don't know
Some
All

Have you had previous debt advice *

No previous advice
Debt Management Plan
Formal insolvency solution
Telephone advice eg: National Debtline
Online - browsing / research
Online - webchat / email
Advice from Citizens Advice
Other face to face advice

Have you tried and failed to set up a payment plan, or set up a payment plan but failed to keep up payments? *

Please tell us what you have tried *

Do you have any of the debts listed below? *

Mortgage Arrears
Rent Arrears
Secured loan arrears
Council tax
TV licence arrears
Hire Purchase (HP) / Conditional Sale
Gas
Electric
Dual Fuel
Water Arrears
Child support arrears
Magistrates Court Fine Arrears
National Insurance Contribution Arrears
Income Tax Arrears
HMRC Tax Credit Overpayment
Benefit overpayment (not Housing Benefit)
Budgeting advance on Universal Credit
Short Term Benefits or Universal Credit Advance
Friends / Family
Fixed Penalty Notice (driving / vehicle related)
Fixed Penalty Notice (non driving related)
Penalty Notice for Disorder (PND)
None of the above

Mortgage 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 owed
Yes - but I can only provide an estimate of the amount owed
No

Please 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)? *

Do you have any assets eg: property, car, savings. other? *

Value 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? *

Do you have a private or company pension? *

Is your private or company pension: *

Defined benefit / final salary
Defined contribution

What is your estimated pension pot? If you do not know please enter 0.01 *

Can you provide detailed information about your income and spending? *

What is your estimated surplus income (how much money do you have left at the end of each month) *

None
£75 or less
Between £75 and £100
More than £100

Please 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? *

What kind of emergency is it? *

Eviction - I have an eviction notice to leave the property on
Bailiff's visiting
No money for food or heating
Having gas, water or electricity disconnected
I have a statutory demand or creditor's petition for bankruptcy and need to respond
Court appearance - I need to attend for a possesion hearing
Money taken directly from bank account
Arrest
Other - I have a committal warning for non payment of council tax and need to respond by
Other – 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? *

Do you have internet access and are you happy using it on your own? *

Do you feel that you have been discriminated against in one or more of the areas below? *

Age
Disabilty
Gender reassignment
Marriage or civil partnership (in employment only)
Pregnancy and maternity
Race
Religion and belief
Sex
Sexual orientation
No - I don't feel I have been discriminated against

Please give details of the discrimination *

Please confirm that you are ready to submit your responses *

Submit