Test form Step 1 of 4 25% This form is split into 4 steps. Step 1 is about your privacy and checks if this is the right service for you. Step 2 is used if someone else is completing this form on your behalf. Step 3 is about you and the help you need. Step 4 is for Equalities and Monitoring Information. The form is not long, but if you cannot complete it in one go, click on the ‘save and continue later’ button to save your answers. You can then go back and complete it at a later time.Step 1This step is about your privacy and checks if it’s the right service for you Privacy Our online form below allows you to request a call back or email from one of our Advisers. Before you share your information with us, it’s important you know what happens with this information and that you agree with it. Please read the information below, and see our privacy policy for more details. If you would like us to email you advice it’s important that you are confident no one else can access your email account. We suggest you don’t use a work account because other people may have access to this information. It’s important to remember that emails may not be encrypted and can be intercepted so do not ask us to email you advice if you want to maintain strict online security and confidentiality – a telephone call is more secure than email. We will store any information provided in the form for as long as is needed to deal appropriately with your enquiry, for the purpose of providing you with an advice service. By sending this form you are consenting to share your information with Moneyworks’ Partnership organisations (Money Advice Plus/ Citizens Advice Brighton and Hove/ Possability People and St. Lukes Advice Service) for the purpose of providing advice on your enquiry. Consent(Required)I have read the privacy information above and are happy to proceed. Yes Your locationDo you live in Brighton & Hove?(Required) Yes No This service can only assist people who live within the Brighton and Hove Area. Step 2Step 2 is used if someone else is completing this form on your behalf Are you completing this form on someone else’s behalf?(Required) Yes No Please confirm that you have the person’s consent to contact us.(Required) Yes No We cannot proceed with the enquiry without your client’s consent for you to contact us. Please can you provide your contact details and confirm that you have their consent?What is your relationship to the person this form?Your name(Required) First Last Email(Required) Phone(Required)If you are a professional, who do you work for and what is your role?Who would you like us to contact:(Required) You The person this form is about Please upload the person’s signed consent for us to speak to you on their behalf(Required) Drop files here or Select files Accepted file types: jpg, png, gif, pdf, doc, docx, Max. file size: 16 MB, Max. files: 2. Step 3This step is about you and the help you need.Name(Required) First Last Email Date of birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address(Required) Street Address Address Line 2 City Postcode Phone number(Required)Phone messagesI give permission for the advice partnership to leave me a voicemail:(Required) Yes No I give permission for the advice partnership to send me a text message:(Required) Yes No Which of the following times would be best for us to call you?(Required)Please tick all that are appropriate: Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Do you require an interpreter?(Required) Yes No Please let us know what language you require an interpreter for(Required)Do you live with anyone else?For example, do you live with a partner or children? If you live with children, please let us know their ages .HousingTick all that apply to your current housing situation Homeless Rent from private landlord Rent from social landlord (housing association) Rent from council Mortgage / Owner Occupier Temp Accommodation Living with family and friends Are you(Required) Working Receiving benefits Working and claiming benefits Caring for somone who receives a disability benefit Other Do you have any Physical or Mental Health problems that limit your day to day activities?(Required) Yes No If Yes, please describe your condition:(Required) Mental Health Condition Learning Disability/Difficulty Physical Impairment Sensory Impairment Are you engaged in Secondary Mental Health Care?(Required)(this means you are likely to be working with the East/West ATS, a Lead Practitioner, Psychiatrist or the Crisis Team) Yes No Please explain how we can help you with your appointmentHave you experienced, or are you experiencing domestic abuse? Yes No We will add you to our waiting list but, in the meantime, you may also benefit from contacting the Financial Support Line. This is a nationwide phone advice line for victims of domestic abuse and can only be accessed by calling this number: 08081 968845 (Mon-Fri 9-5). This form does not provide access to the Financial Support Line.What do you need help with?Tick all that apply Benefits Debt Immigration Heating costs Work & BenefitsDo you need help with the following?Please tick all that apply Check your benefits are correct Understand the impact of a change in circumstances in your benefits Help applying for benefits or appealing a decision Help applying for benefits for someone else in your household Please let us know what benefits you currently receivePlease let us know the type and amountDo you have any savings? Under £6,000 £6,000 to £16,000 £16,000 or more Are you a full-time Carer for someone who receives Attendance Allowance (AA), Personal Independence Payments (PIP), or Disability Living Allowance (DLA)? Yes Do you want to appeal a benefit decision? If so when did you receive your decision letter?Upload any letter (optional)You can use this field to upload a scan of any letter you have received, if you are able toAccepted file types: pdf, jpg, png, gif, jpeg, Max. file size: 16 MB.Use this section to let us know anything else about your benefit situation.Debt AdviceYou can find out more about the types of debt by visiting Brighton & Hove CAB's website (opens in new window.Do you have any of the following primary debts?Tick any that apply. Rent arrears Mortgage arrears Council tax arrears Gas or electricity bills Phone or internet bills TV licence payments Court fines Overpaid tax credits Payments for goods bought on hire purchase or conditional sale Unpaid income tax, National Insurance or VAT Unpaid child maintenance Other debts credit card or store card debts catalogue debts unsecured loans including payday loans unpaid water bills - your supplier can’t cut off your water supply overpayments of benefits - apart from tax credits unpaid parking tickets - these are called Penalty Charge Notices or Parking Charge Notices Money you owe to family and friends Are bailiffs involved?(Required) Yes No Let us know the debts where bailiffs are involvedAre you being threatened with eviction?(Required) Yes No Tell us more about your debt situationPlease use this section to let us know about your debit situationHeating CostsDo you struggle with the cost of heating your home?(Required) Yes No Have you received a fuel grant from the Energyworks Project at Citizens Advice?(Required) Yes No You can use this space to provide us with further information if needed.ImmigationDo you need advice about your immigration status?What is your preferred spoken language? Step 4Equalities Monitoring InformationThese questions help us to make sure we are providing a service for all sections of the community. You don’t have to answer them .EthnicityPlease selectAsian or Asian British BangladeshiAsian or Asian British IndianAsian or Asian British Other BackgroundAsian or Asian British PakistaniAsian or Asian British AfricanAsian or Asian British CaribbeanAsian or Asian British Other BackgroundChineseEastern EuropeanMiddle EasternMixed Other BackgroundMixed White & AsianMixed White & Black AfricanMixed White & Black CaribbeanOtherPrefer not to sayRomany, Gypsy, TravellerUnknown/Refused to answerWhite BritishWhite IrishWhite OtherGenderPlease selectFemaleMaleNon BinaryOtherUnknownAre you Transgender?Please selectNoPrefer not to sayTransgenderReligionPlease selectAgnosticAtheistBuddhistChristianHinduJainMuslimNo ReligionOtherOther Philosophical BeliefPaganPrefer Not to SaySikhSexual OrientationPlease selectBi SexualClient Declined to AnswerHeterosexualHomosexualNot KnownOtherCommentsThis field is for validation purposes and should be left unchanged.
