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Your name
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Your email address
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Your telephone number
Your post code
Date you are completing this form
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Day
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Month
Year
What advice are you enquiring about?
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Benefits advice
Debt advice
Housing advice
Employment advice
Energy advice
Any other advice topic
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Benefits Advice
Is there an urgent deadline, e.g. appeal deadlines, dates for forms to be returned?:
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Yes
No
Not sure
Who is in your household?
Just me
Me and a partner
Me and other adults (family/friends)
Me and a child or children
Me, a partner and a child or children
Me and other adults but not friends/family
Any other arrangement
How much does your household have in savings?
Under £6,000
Between £6,000 and £10,000
Between £10,000 and £16,000
More than £16,000
Do any of the following apply to you or someone in your household?
Disabled/long-term health condition
Carer
Student
In hospital, residential care or prison
Subject to immigration control
Retired
What does your issue relate to?
General benefit entitlement
Attendance Allowance
Council Tax Reduction
Employment and Support Allowance (ESA)
Housing Benefit
Job Seekers' Allowance (JSA)
Pension Credit
Personal Independence Payment (PIP)
Tax Credits (Working or Child)
Universal Credit
Any other benefit
Please tell us about your issue
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Have you contacted any Citizens Advice service about this issue before?
Yes
No
Not sure
Anything else we need to know
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Debt advice
Are there any emergencies? E.g. bailiffs, court dates
What does your issue relate to?
No money to pay debts
Disagree that I owe money
Problems with a current debt arrangement
Rent or mortgage arrears
Utility debts (including electricity, gas, water, telephone and broadband)
Council tax debt
Credit card or catalogue debts
Parking fines
Magistrates court fines
Loans
Any other debt issues
Please tell us about your issue
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Have you contacted any Citizens Advice service about this issue before?
Yes
No
Not sure
Anything else we need to know
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Housing advice
Are you homeless, threatened with eviction or do you have to leave your home for another reason (e.g. domestic abuse)?
Yes
No
Not sure
Is there an emergency, e.g. court dates, eviction notices, court warrants, threat of violence?
Yes
No
Not sure
What is your housing type?
Private rental property
Council or housing association property
Living with friends/family
Own the property outright
Buying the property through a mortgage
Homeless
Any other housing status
How long has this been your housing status?
Does your landlord live in the property?
Yes
No
Not applicable
What does your issue relate to?
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Repairs
Rental costs
Eviction
Deposits
Letting agents
Finding a property
Getting a council or housing association property
Unable to pay rent/mortgage
Court hearings
Other housing issue
Please tell us about your issue
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Have you contacted any Citizens Advice service about this issue before?
Yes
No
Not sure
Anything else we need to know
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Employment advice
Is there an emergency, e.g. potential dismissal, nearly 3 months since incident occured?
Yes
No
Not sure
What is your employment type?
Self-employed
Fixed-term contract
Full or part-time employee
Worker or agency worker
Unemployed/unable to work
Any other employment type
How long has this been your employment status?
What does your issue relate to?
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Contracts
Disciplinaries
Pay
Leave entitlement
Maternity/paternity issues
Discrimination
References
Health & safety or working conditions
Resigning
Other work issue
Please tell us about your issue
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Have you contacted any Citizens Advice service about this issue before?
Yes
No
Not sure
Anything else we need to know
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Energy advice
Is there an emergency, e.g. court dates, debt collectors, fuel running out?
Yes
No
Not sure
What does your issue relate to?
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Billing problems
Can't afford my bills/to top up
Energy grant for bills
Grants for improving my home
How to reduce my energy usage
Smart meters
Complaints against supplier
Supplier has gone bust
Problems with my supply
Other energy issue
Please tell us about your issue
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Have you contacted any Citizens Advice service about this issue before?
Yes
No
Not sure
Anything else we need to know
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Any other advice topic
Are there any emergencies?
Yes
No
Not sure
If relevant to your issue, who is in your household?
If relevant to your issue, please include details of your household income
What does your issue relate to?
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Immigration
Health and care
Support with food or grants
Family and relationships
Problems with buying things or using a service
Transport and travel
Discrimination
Domestic abuse
Legal or court issues
Other issue
Please tell us about your issue
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Have you contacted any Citizens Advice service about this issue before?
Yes
No
Not sure
Anything else we need to know
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