Request Advice for Yourself Please use this form to request advice from Citizens Advice Hull and East Riding If you wish to know more about our Data Protection and Privacy policy, please click here Are you requesting advice for yourself?YesNo If you are requesting advice for somebody else please use our professional form here We need your consent to record and use your special category personal data. If you do not consent to us recording special category data and your enquiry relates to this, the advice we give you may be limited and not specific to your circumstances. ***If you do not wish for us to store this information for use in both monitoring and in relation to your enquiry, please do not provide it*** Before continuing, please confirm that you consent to Hull and East Riding Citizens Advice storing your detailsYesNo We need your consent to record and use your special category personal data Special Category Information Pleases provide any special category data that you consent to us holding. If you do not consent to us storing your special category data, please select "Prefer Not to Say" Ethnicity?—Please choose an option—Prefer No to SayWhite - BritishWhite - EnglishWhite - ScottishWhite - WelshWhite - Northern IrishWhite - IrishWhite - Gypsy or Irish TravellerWhite - OtherMixed - White & Black CaribbeanMixed - White & Black AfricanMixed - White & AsianMixed - OtherAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - OtherBlack or Black British - AfricanBlack or Black British - CaribbeanBlack or Black British - OtherOther - ArabOther - Any OtherUnknown Health Conditions —Please choose an option—Prefer No to SayLong TermDisabledMental HealthPhysical Impairment (non-sensory)Visual ImpairmentSpeech ImpairmentHard of HearingDeafLearning DisabilityCognitive ImpairmentMultiple ImpairmentsOther Disability or Type not given Trade Union Membership —Please choose an option—Prefer No to SayYesNo Accessing our service Do you need an interpreter?YesNo If yes, what language do you need? The following 2 questions are asking for your special category data. Please ensure you have given us permission to store this in the section above. Do you have any communication needs? Do you have any mobility needs? Personal Details Your first name Your surname name Date of Birth Do youlive in Hull or East Riding Council Areas?HullEast Riding Do you have a registered home address?YesNo Your address Postcode Telephone number Email address Your GP Surgery—Please choose an option—CHCP – City CentreCHCP – East Park Park Health CentreCHP Ltd – BransholmeCHP Ltd – Southcoates & MarfleetClifton House Medical CentreDelta HealthcareDr GT HendowEast Hull Family PracticeField View SurgeryGoodheart SurgeryHastings MedicalHaxby – Burnbrae SurgeryHaxby – Calvert & NewingtonHaxby – Kingswood & Orchard ParkJames Alexander PracticeKingston HealthLaurbel SurgeryMarfleet Group PracticeModality HullNewland Health CentreNorthpointOrchard 2000Princes MedicalRaut PartnershipSt Andrews Group PracticeSutton Manor SurgerySydenham House Group PracticeThe Avenues Medical CentreThe Bridge GroupThe Oaks Medical CentreWilberforce SurgeryWolseley Medical CentreAnlaby SurgeryBeverley - Greengates Medical GroupBeverley - Manor Road SurgeryBeverley - North Beverley Medical CentreBeverley - The Old Fire Station SurgeryBridlington - Field House SurgeryBridlington - Manor House SurgeryBridlington - Practice OneBridlington - Practice TwoBridlington - Practice ThreeBridlington - Wolds View SurgeryBrough - The Ridings Medical GroupCottingham - King Street Medical CentreDriffield - The Medical CentreDriffield - The Park SurgeryEastgate Medical GroupGoole - Bartholomew Medical GroupGoole - Montague Medical PracticeGilberdyke Health CentreHessle - Park View SurgeryHessle Grange Medical PracticeH.O.S.M - The Ridings Medical GroupHowden Medical PracticeHolderness HealthLeven and Beeford Medical PracticeMarket Weighton PracticeNorth Ferriby SurgerySnaith and Rawcliffe Medical GroupSouth cave - The Ridings Medical GroupWillerby and Swanland SurgeryUnknown/Prefer Not To Say Are you a serving or former member of the armed forces?—Please choose an option—YesNo Armed Forces Details Are you...? A Military SpouseCurrently servingRetiredA dependant of a serving member of the military or a veteran In which service did you serve? Royal Air ForceBritish ArmyRoyal NavyReservist What is your service number? What is/was your period of service? From: To: Were you medically discharged? YesNo Are you in receipt of...? War PensionArmed Forces Compensation PaymentsPersonal Independence PaymentsCarers AllowanceAFPS 75/05/15 Pension Do we have permission to contact you via phoneYesNo Do we have permission to contact you via emailYesNo Do we have permission to contact you via letterYesNo Main Reason for Referral Please tell us the reason you require support. (please select one option only)—Please choose an option—BenefitsHousingEnergy - Supplier IssuesDebtRelationship breakdown/familyEmploymentOther-(Utilities, immigration, consumer or other legal matters) What is your household situation? Live AloneCoupleLive with childrenShared propertyNone of the above How many bedrooms does your home have? What is your employment status? WorkingNot WorkingRetired How are you housed? Owned OutrightBuying with the mortgagePrivate rentedCouncil rentedHousing associatonLiving with family or friendsHomeless Have you been issued with... Any notice seeking possessionNotice of court proceedingsWarrant for possession Do you have any assets? i.e. a car, savings, house, motorcycle? Roughly, what is your total monthly income Do you have more or less than £75 spare monthly income, after all of normal expenses were met?MoreLess Roughly, what is your total amount of debt? Do you have any of these priority debts? Rent/mortgage arrearsGas/electricityCouncil taxMagistrate's FineHire purchaseNone of these debts Are you aware of any of the following urgent actions being taken against you? Possession or EvictionBailiffsDisconnection of fuel supplyCommittalStatutory demand for bankruptcyNone of these actions Are there any deadlines or key dates? Please tell us about your issue. Please provide as much detail as possible in the text box below Do any of the below apply to you? I am being evicted/or losing my homeI have to appear in CourtI have an urgent deadline (e.g. from the DWP)No urgent issue Do you have any key dates? Energy Details Who is your energy supplier? Feedback Can we contact you for feedback?—Please choose an option—Prefer No to SayYesNo If so, can we contact you via: PhoneYesNo EmailYesNo LetterYesNo
