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Your full name *
Phone *
Please specify the surgery you work in *
Please list your organisation *
Please list your team *
Please list your job role *
Address (including postcode)
Phone number *
Will you need an interpreter? If yes, please state which language you require
Do you have any communication needs? If so, please state what they are
Do you have any mobility issues which need to be considered if attending an in-person appointment? If so, please state what they are
Address (house number, street, town / city). Enter 'no fixed abode' if no address. *
Postcode (type in None if no address) *
Please state the term you (the client) prefer to use to describe your gender
Please state the term you (the client) prefer to use to describe your sexual orientation
Please state the religion
Please state which other health condition you (the client) has
Phone number (client) *
If you (the client) need an interpreter, please say which language is required
If you (the client) have any communication needs, please state what they are
Please give the name and location of the surgery *
What is the main source of income? *
Please tell us about any benefits already being claimed (including how long they've been claimed for)
Do you (the client) have any mobility or care needs? If yes, please give details
Please state the name of the form *
Is there a deadline for the form(s) to be completed and returned? If yes, please give the date
Please tell us more about the incorrect UC payment, or the benefits decision you want to challenge. Include any important deadlines. Please state whether the DWP has been contacted already *
Please tell us about the benefits problem (include deadlines and action taken so far) *
Please tell us more about the consumer problem, any action taken so far and details of any important dates including when services / goods were purchased *
Please give their address and other relevant information. If the disagreement involves more then one person please use this box to list their details *
Please tell us more about the separation or arrangements for access to children. Please state any action taken so far *
Please tell us who has died and what advice you need *
Please tell us more about the family / relationship issue and any action taken so far. *
Please provide details of the problem and any action taken so far *
What is the deadline for leaving the property? *
When did you (the client) move into the property? *
Please give details of the court hearing and what the decision was *
Please tell us about the problem with Council Tax, action taken so far, key dates and any court action *
Please tell us about the problem with rent / mortgage, action taken so far, key dates and any court action *
Please tell us about the problem with TV Licence, action taken so far, key dates and any court action *
Please tell us about the problem with water bill, action taken so far, key dates and any court action *
Please tell us about the other bills problem, action taken so far, key dates and any court action *
Please tell us about the energy problem and any action taken so far including key dates and any court action *
Please tell us more about the settlement issue, any action taken so far and details of any important dates. *
Please tell us what advice you (the client) need about your immigration status *
Please tell us more about the immigration issue, any action taken so far and details of any important dates *
Please tell us about the work problem and action taken to try to resolve it. Include any important dates or deadlines. *
Please tell us more about the dismissal including any action taken so far and desired outcomes *
Number of people in the household (including yourself) *
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 there are more than 5 *
Number of vehicles in household *
Please list the name and address of the partner / ex partner who may be receiving advice from us *
Please tell us about anything else you (the client) have tried to deal with your debts? *
Mortgage arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
Mortgage arrears: Please state the monthly repayment amount (if known)
Rent arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
Rent arrears: Please state the monthly repayment amount (if known)
Secured loan arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
Gas arrears: Please state the monthly repayment amount (if known)
Electric arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
Electric arrears: Please state the monthly repayment amount (if known)
Dual fuel arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
Duel fuel arrears: Please state the monthly repayment amount (if known)
Water arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
Water arrears: Please state the monthly repayment amount (if known)
Child support arrears: Please state the total amount owed. Please enter 0.01 if amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
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 amount owed is not known. *
Penalty Notice for Disorder (PND): Please state the monthly repayment amount (if known)
Please list the creditors to whom money is owed (and the amounts) *
If you don't know who the creditors are, or how much is owed, give a rough estimate e.g. £1000 to 5 creditors *
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 *
Please list any other assets and their value *
Estimated pension pot? If not known, please enter 0.01 *
Please list the income sources here *
Please refer to the box above and list details of your spending. *
Please list any key dates e.g. court date, bailiffs / eviction date, response deadline for statutory demand or committal warning *
Please give details of the discrimination *
Please tell us about the problem, including any action taken so far and key dates / deadlines *
