0116 2421120

enquiries@advice-cals.org.uk

Supporting Leicester and Leicestershire since 1979

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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.

Self-Referral Form

If you would like to speak to one of our team about accessing support, please provide details about your issue using the form below and one of our team will be in touch to discuss how we may be able to help.

We are sorry that we're currently unable to accept self-referrals for housing advice via our web form or email. If you require housing advice, please contact us by telephone on 0116 242 1120 to speak with one of the team.

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

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

Our team will aim to contact you to discuss your issue at you indiciated time preferred with the next 7 days. If you require advice on an issue not listed above, please contact us via email at enquiries@advice-cals.org.uk.