Client Referral FormClient ConsentIn order to process this referral, we need to record details of your client. This will include ‘personal data’ (information which can be used to identify the client, such as their name, date of birth, contact details, etc.) and may include Special Category Data (e.g. Ethnicity, Health Conditions, Religion, Sexual Orientation, Trade Union Membership). We will discuss our use of the information further with the client when we first contact them. The information will be stored on a shared electronic case management system accessed only by members of the Citizen Advice service. To comply with data protection legislation, we must ensure there is consent from the client to record those details. To submit this form, you must have gained prior consent from the client to send us all the information you have provided below. For more information about what we do with your information please read our Privacy Notice.Confirmation* I have gained the client's consent to make this referral and share this information Before you start...Prior to making a referral have you or your client researched the issue via the Citizens Advice Website, by using our Virtual Adviser tool or by checking Benefit Entitlement. If you have, or if you feel further advice and assistance is needed, please continue. Otherwise please exit this form and explore the considerable amount of advice and assistance available online.Confirmation* The client/I have researched the issue and need further advice or assistance Referrer's DetailsName* Title MrMrsMissMsDrProf.Rev. First Last Job Title/RoleOrganisation*Phone Number*Email Address* About Your ClientPlease Select Your Client's Local Citizens Advice*This is the district/area of the county they live inPlease SelectMendip AreaSedgemoor AreaSouth Somerset AreaTaunton Area (Taunton, Wellington, Norton Fitzwarren, Wiveliscombe & near by)West Somerset Area (Minehead, Watchet and Williton & near by)Name* Title MrMrsMissMsDrProf.Rev. First Last Date of Birth* Day Month Year Gender*Please select...MaleFemalePrefers a different Term (Other)WithheldAddress* House Number or Name Post Code Phone Number*PLEASE NOTE - when contacting your client OUR number may show as Withheld or Unknown. Please make sure your client is aware of thisIs Your Client Happy to Receive: Texts Voicemails Emails Post Email Address Does anyone else live in your client's home?* Yes No Other People in Your Client's Home*These are people that are part of your client's household. Please do not include details of third parties such as lodgers or house mates Other Adults Children Number of Other Adults*12345+Relationship of Other Adults to the ClientFor example, husband, wife, partner, adult child/children, parent/s etc.What are the ages and sexes of the children?*What benefits is your client's household currently in receipt of?*Please tick all that apply Attendance Allowance Carers Allowance Child Benefit Council Tax Support Disability Living Allowance Employment Support Allowance Housing Benefit (not as part of UC) Income Support Job Seekers Allowance Maternity Allowance (not SMP) Pension Credit Personal Independence Payment (PIP) State Retirement Pension Universal Credit Working or Child Tax Credits Other None Unknown Benefit AmountsIf you or your client can tell us how much they get from any of the benefits above please list them belowHow much does your client have in savings, capital or investments?*We need to know this as savings and capital have a direct impact on access to a range of benefits and other services. An approximate value is finePlease tell us anything else we should know (including anything for risk assessment purposes)*Is there any other support your client might need to help them access advice? Please consider physical help, support and language difficultiesAbout Your ReferralWhat Does Your Client Need Advice About or Help With?*Please tick all that apply Benefits Employment Family/Relationships Housing Money/Debt Other Employment DetailsIs your client employed?* Yes No EmployerNormal working patternEnter the normal hours worked each week and on which daysEarnings if knownApproximate weekly or monthly take home pay would be very useful to knowLength of service with this employerTo the nearest number of years and monthsHousing DetailsWhat is your client's housing situation?* Buying Home (mortgage) Own Outright Rent Privately Rent from a Social Housing Provider Homeless - Sofa Surfing Homeless - Street homeless Social housing provider*AbriAsterHastoeHomes in SedgemoorLivewestMagnaSomerset West & Taunton CouncilStonewaterOtherHas your client made a homelessness application?* Yes No Money/DebtDetailsDoes your client have any of the following debts? Council Tax Arrears Electric/Gas Arrears Rent Arrears Unknown Does your client have any of the following debt emergencies? Court Action Bailiffs Visiting Electric/Gas Disconnection Eviction Unknown Please advise of any known dates relating to these emergenciesIt is important for us to know about dates in case we need to take any urgent actionReferral DetailsFurther details about your referral*Please provide some details about the issue the client is facing or the advice they need, and any information we should be aware of prior to contacting the clientCan your client provide any documents that may help us to assess their situation and provide advice?*For example, benefit letters, UC payment statements, bank statements and council tax bills. If so, and they are available electronically or you can take pictures of them, please upload them at the end of this form Yes No AttachmentsIf you wish you may attach a document(s) to provide us with further information. Please be aware this will not be encrypted when it is sent to us Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 5.CommentsThis field is for validation purposes and should be left unchanged.
