Please enable JavaScript in your browser to complete this form.Why are you contacting us? *Please choose...I would like to refer a client to your serviceI'm seeking help for myselfWe are sorry but this fund has now been fully allocated.If you need help with your bills, please call our Adviceline (free phone) 0808 278 7897 - Mon to Fri 9.30am - 2.30pmWhat is the name of your organisation? *What is your name? *FirstLastWhat is your email? *EmailConfirm EmailWhat is your phone number? *How do they heat their home? *Please choose...Bottled gasCoalElectricityGasOilWoodOtherIf other, please describe how they heat their home.Who is their current supplier? *How do they pay for their supply? *Please choose...Direct debitIn advance to supplierInvoicedPrepayment meterQuarterly billsSmart meter/appWhat is their fuel account number?What is your client's first name? *What is your client's last name? *What is your client's date of birth? *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your client's address? *Address Line 1Address Line 2CityState / Province / RegionPostal CodeWhat is your client's phone number? *Please tick which ways your client is happy for us to contact them by. *PhoneVoicemailTextEmailLetterPlease tick as many as possible to make it easier for us to support them.What is your client's email? *EmailConfirm EmailPlease tell us a little bit about the householdWhat is their housing status? *Please choose...OwnedRented privateRented social housingOther (Please specify)Please provide details of your client's housing statusHow many people are there in the household? Selected Value: 0 This data is used to determine how many people are being impacted through this project.How many are adults; 18 years old and above? *How many are dependents; between 13 - 17 years old? *How many are dependents between 0 - 12 years old? *What is their employment status? *Full-timePart-timeStudentFull-time carerNot workingOther (Please specify)Please tell us about their employment situation *Currently, are they receiving benefits? *Please choose...YesNoWhat benefits are they receiving? *Income SupportIncome-based Job Seeker's Allowance (JSA)Income-based Employment Support Allowance (ESA)Pension Credit Guaranteed CreditHousing BenefitUniversal CreditWhat is the combined household income each month? *Please include all forms of income linked to each member of the household; such as wages, Universal Credit, money from self-employment, Tax Credit, Job Seeker's Allowance (JSA), Employment and Support Allowance (ESA), Personal Independence Payments (PIP), Disability Living Allowance (DLA).How much does your client spend on heating and electricity each month? *Your energy detailsDoes your client top up their prepayment meter by either smartcard or key? *Please choose...YesNoPlease enter the card number or key number to allow the voucher to be attached to the account. *This avoids the voucher being used by another personDoes British Gas supply either the gas or electricity? *Please chooseYesNoHow would your client like to receive their fuel top up voucher? *Please choose...LetterEmailHow has your client been affected by Covid-19? *Employment issues (lost job, furloughed, made redundant...)Reduced income (loss of job, reduced hours...)Increased bills (food, utilities...)Childcare issues Mental health issues (stress, anxiety, depression)Physical health issues (new condition or worsening of existent condition)Family or relationship issuesDiscrimination issues (age, race, gender, religion...)Data protection *By ticking this, your client agrees to Citizens Advice - Bath & North East Somerset storing and using information about them and consents to being contacted by the charity.We keep client details on our database which is confidential to Citizens Advice. The details we take are to enable us to give 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. Submit
