0116 2421120

enquiries@advice-cals.org.uk

Supporting Leicester and Leicestershire since 1979

Home
About Us
Our Advice Services
Volunteering
Work With Us
- Work With Us
- Vacancies
Contact Us
- Contact Us
- Tell Us What You Think

Home
About Us
- Our History
- Our Aims
Our Advice Services
Volunteering
- Volunteer with us
- Become a trustee
Work With Us
- Vacancies
Contact Us
- Tell Us What You Think

MAKE A REFERRAL

Please complete the form below, providing us with as much information as possible to assess how we are best able to support you.

Referral Form

Once we have received and processed your referral, one of our team will be in touch to discuss how we may be able to help.

Please note that in some instances,we may need to contact you to complete an initial assessment and collect further details to establish if we can help you. This process is most quickly completed via telephone.

Your Details

Please leave blank:

Full Name:

Town:

Date of Birth:

Email:

Address:

Postcode:

Gender:

Telephone:

How did you hear about us:

Contact Preferences

Please use the boxes below to indicate your consent and preference for how our team contact you:

Can we contact you by phone?

Can we contact you via SMS?

Can we contact you by email?

Can we contact you by post?

Can we leave a voicemail message if we are unable to get hold of you?

Preferred method of contact:

Preferred time of contact:

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Support required (please tick all that apply)

Debt

Tick if applicable:

Council tax arrears

Rent /Mortgage arrears

Secured Loan Arrears

Court fines

Benefits Overpayments

PCN/Parking Fines

Utility Arrears (Gas/Electric/Telecoms)

TV licence Arrears

Hire Purchase Arrears

Unpaid Tax, National Insurance or VAT

Child maintenance arrears

Other debts or arrears

Housing

Tick if applicable:

Suspension of Warrant

Possession- Section 21 Notice/ Accelerated Claim

Possession- (Anti-social behaviour or other)

Homelessness

Property Disrepair

Rehousing Issues (Including banding, overcrowding and medical reason issues)

Rent Arrears:

Housing Association

Local Authority

Private Landlord

Other

Immigration

Please select from the drop-down menu and provide additional details:

Secondary Issue:

Welfare Benefits

Tick if applicable:

Challenging a Universal Credit (UC) Decision

Challenging an Employment & Support Allowance (ESA) Decision

Challenging a Housing Benefit (HB) Decision

Challenging a Council Tax Support (CTS) Decision

Challenging Personal Independence Payment (PIP) Decision

Disability Living Allowance (DLA) Issue

Child Benefit (CB) /Pension Credit (PC) /Working Tax Credit (WTC) Issue

Other Issue:

Additional Information

Please provide any additional information here:

Data Protection and Privacy

Contact Request:

Please contact me using the information provided for the purpose of providing me with support relating to the issues I have indicated in this form.

Home

Welfare Benefits Advice

CONTACT

Registered office:

1st floor, Epic House, Charles Street, Leicester, LE1 3SH.

Tel: 0116 242 1120

Email: enquiries@advice-cals.org.uk

VAT Number: 775380306

Privacy Notice

Privacy | Cookies |

Website design Leicester — by it’seeze

Our site uses cookies. For more information, see our cookie policy. Accept cookies and close

Reject cookies Manage settings