Litigants in Person Advice Form"*" indicates required fieldsOnly refer your client if you can answer yes to both of the following questions:Has your client experienced domestic abuse?* Yes NoDoes your client have a legal issue against their perpetrator?*For example, to do with their home, children, finances, divorce/separation. Yes NoClient 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 the information below.Referrer's DetailsName* Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Job title/role*Organisation*Phone Number*Email* Enter Email Confirm Email How are you assisting the client?*Will you be continuing to support your client after you've referred them?* Yes NoAbout your clientName* Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Date of Birth* DD slash MM slash YYYY Gender*MaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerAddress* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Can we write to this address?* Yes NoEmail* Enter Email Confirm Email Can we email?* Yes NoPhone Number*Can we phone?* Yes NoCan we text?* Yes NoCan we leave a voicemail?* Yes NoAbout Their SituationNationalityHousehold type*Please Select...Own outrightBuying Home (mortgage etc)Shared OwnershipCouncil/ALMO tenantHousing Association/RSL tenantPrivate tenantHoused through job/businessStaying with Relatives/Friends (rent free)Staying with Relatives/Friends (paying rent)HostelPrisonHomeless (inc. B&B tenant)Residential Accommodation (Nursing/Care homes)OtherNot knownMarital status*Please Select...SingleMarriedCivil Partnership (CP)CohabitingSeparated but legally married/CPDivorced/CP dissolvedWidowed/surviving partnerNot knownEmployment*Please Select...Employed >30hrs p/wEmployed <16hrs p/wEmployed between 16-29hrs p/wUnemployed - seeking paid workSelf-employedVolunteerRetiredSemi-retiredStudentOn Govt Scheme for EmploymentCarer - ChildrenCarer - Disabled/Older PersonLooking after home - DependentsLooking after home - No DependentsPermanently sick/disabledOtherNot knownReason for referral*Please provide as much detail as possible e.g. relevant background, advice need, what your client has done so far etc.If known, please confirm the name of your client’s perpetrator/abuserPlease provide any other identifying information such as date of birth, address etc. so we can undertake conflict of interest checks.Are there any key dates or urgent deadlines we need to be aware of?* Yes NoIf you ticked yes, please tell us the key dates or deadlines and what they are*Is your client receiving any other specialist support of involvement?* Yes NoIf you ticked yes, please tell us who and how they are assisting*Is there anything else we should know, including anything for risk assessment or safeguarding purposes?Please provide any documents that may help us to assess their situation and provide advice? Drop files here or Select filesMax. file size: 2 MB.CAPTCHAPlease wait for a green tick before clicking submit or leaving this page, otherwise your information will not be processed.PhoneThis field is for validation purposes and should be left unchanged.
