Date of Birth (required)

Ethnicity—Please choose an option—White: 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 OtherPrefer Not To Say/Unknown

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What benefits are you or a member of your household already claiming? (required)

What is the problem with your benefits? (required)

Circumstance (i.e. reasons for being on/claiming benefit – not working, low income, disability, children, housing, etc.) (required)

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What are the goods or services and what is wrong with them? (required)

When did you first find the goods or work was faulty? (required)

Where and when did you buy the goods/services? (required)

How were the goods paid for & do you have a receipt/credit agreement? (required)

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Roughly how much money do you owe? (required)

Do you have any rent/mortgage arrears/council tax/outstanding fuel bills? (required)

Are the debts in your name/joint names? (required)

Any savings or assets (e.g. Car valued over £1000)? (required)

How much can you afford to pay each week? (required)

Do you have a current bank account? (required)YesNo

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Are you:
Employed? (required)YesNo
Self-employed? (required)YesNo

Are you a member of a trade union? (required)YesNo

Are you still working? (required)YesNo

If not, were you dismissed, made redundant, walked out, suspended?

How long have you been employed? (required)

Name of employer? (required)

Do you have a written contract? (required)YesNo

What has happened? (required)

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Are you: (required)MarriedIn a civil partnershipLiving together

How long have you been married, in a civil partnership, living together? (required)

What is your housing status: (required)RentMortgageJoint namesIn one name

Are there any emergencies, e.g. domestic violence, have nowhere to stay? (required)Please select...YesNo

Present situation, e.g. are you still living together? (required)

Are there any children involved? (required)YesNo
If so, what are their ages?

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Who is your current energy provider: (required)

Are you in debt with your current energy provider? (required)Please select...YesNo

Do you currently have electricity and gas available? (required)Please select...YesNo

What type of payment method are you using? (required)Please select...Direct DebitPay-paymentBank TransferOther

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Are you struggling with any household bills? (required)YesNo

Do you have a bank/Post Office account? (required)YesNo

Are you happy/confident searching for best deals i.e. energy/phones/insurance? (required)YesNo

Do you have any money issues preventing you from buying household essentials i.e. Food/energy/white goods? (required)YesNo

Are you confident with household budgeting? (required)YesNo

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Are you homeless, threatened with eviction or have to leave your home for another reason (e.g. domestic violence)? (required)YesNo

Is there an emergency, e.g. court dates, eviction notices, court warrants, threat of violence from somebody? (required)YesNo

If you have a tenancy:
Is it fixed term?YesNo
How long is the term?
Who is your landlord?
Do they live in the same property? (required)YesNo
Do you have any dependent children living with you? (required)YesNo

Housing benefit:
Are you receiving it? (required)YesNo
or
Have you applied for it? (required)YesNo

What is the problem with your housing? (required)

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Is the enquiry about: (required)YouYour partnerOther person

What is nationality of you/partner/other person? (required)

Full details of immigration enquiry: (required)

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Can you briefly describe what you want help with? (required)

Please enter other other other other other problems here, not