Benefits and debt client referral form

What does your client require help with? *

Help To Claim Universal Credit
Debt
Mind clients for Polly

Client name

Client date of birth//

Client address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

If your client has no fixed abode, please enter 'No fixed abode' in the House name/number fields, 'BANES' in the City and County fields, and 000000 for the postcode

Please tick all the ways the client is happy to be contacted by us? *

Please tick as many as possible to make it easier for us to support you. If they have no fixed abode, please ensure that we have at least 1 way of contacting them other than by letter.

Your name *

First

Last

Your organisation *

Your phone number *

Please give us as much background as possible to help us when we contact the client

Data protection *

Please tick this box if your client has consented to being contacted by Citizens Advice - Bath & North East Somerset

We keep client details on our database which is confidential to Citizens Advice. The details we take are to enable us to give clients the appropriate advice. They aren’t accessed by anyone else except in the case of gathering feedback on our service which is also done confidentially. We don’t sell client data to anyone.

Adviceline

Citizens Advice Bath & North East Somerset

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Benefits and debt client referral form

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