Self-Referral Form
If you need assistance from CHAP, please complete this form, providing as much detail as possible. A member of our team will aim to call you within 24-hours. If the matter is urgent, or if you haven't heard from us, you can contact us on 030 0002 0002, or email us directly on adviceandinfo@chap.org.uk.
Date
*
/
Day
/
Month
Year
Date
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Town
State / Province
Postcode
Do you live with a partner?
*
Yes
No
Partner's Name - we need to know this information to allow us to check for conflict of interest.
First Name
Last Name
Do you have any children in your household?
*
Yes
No
If yes, how many children?
How would you prefer us to contact you?
*
Telephone
Email
Text
Letter
Phone Number
Please enter a valid phone number.
Format: 00000 000000.
Email Address
example@example.com
When is the best time to call you?
*
Morning
Afternoon
No preference
How did you hear about our service?
*
Word of Mouth (friends/family)
Website
Social Media
Project Flyers/Posters
Previously used service
Signposted by another service
If signposted by another service, please specify:
What do you need help with? (select all that apply)
*
Welfare Rights (benefit check, application, appeal, etc.)
Housing (application, appeals, private let, eviction, rent/mortgage issues, etc.)
Money/Debt (budgeting, debt options, etc.)
Please give an outline of your circumstances and what you need help with: (including any deadlines/urgent issues/relevant information)
*
Submit
Should be Empty: