RBKC Services Referral Submission Form — Citizens Advice Kensington and Chelsea

As part of our quality of advice promise at Citizens Advice, we promise to fully explore the client’s issues and not just the matter for which you are referring them into our service. By receiving this referral form - completed in full - you will help us to see our clients quickly and provide them with the most appropriate support. Thank you for your assistance.

We aim to contact the client within 3 working days to confirm a date and time on which we will contact them to explore the referred issue and any other issues that the client may wish to discuss.

REFERRAL DETAILS

Referring Agency *

'If you selected 'Other' please tell us what department you work for:

Referrer's Full Name *

First Name

Last Name

Referrer's Email *

Referrer's Phone Number *

(###)

###

####

Referrer's Role *

What is your role in relation to the client?

Permission to Refer *

I confirm the client has given me permission to share their details with Citizens Advice Kensington and Chelsea.

CLIENT CONTACT DETAILS

Client's Full Name *

First Name

Last Name

Client's Date of Birth *

YYYY

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's Email

Client's Phone Number

(###)

###

####

Client's Preferred Method of Contact *

Phone

Letter

No Preference

Consent to Record Special Category Data *

The client gives express permission to record and share special category data with Citizens Advice Kensington and Chelsea for the following:

Ethnicity

Health Condition

Religion

Sexuality

Trade Union Membership

None of the above

CLIENT CAPABILITY

Does the client have access to the internet? *

Is the client confident about using the internet to read and understand information? *

Is the client confident in filling out forms, reading and writing? *

Does the client need help with communication or interpretation? *

Does the client have a preferred language (other than English)?

If there are any known risk factors with this client, please tell us here:

REFERRAL ISSUE(S)

Has the client contacted Citizens Advice or anyone else about this issue(s) before? *

What category does this issue(s) fall within? *

Welfare benefits

Housing

Immigration

Consumer

Employment

Family and relationships

Debt

Other

Don't know

Is there a deadline that we need to know about? If yes, please provide us with the date:

YYYY

Issue 1 *

Issue 2 (if applicable)

Issue 3 (if applicable)

FURTHER BACKGROUND INFORMATION

You can help us to progress your client's case faster by completing some optional background information.

HOUSING: Type of accomodation

HOUSING: Cost of accommodation (per month)

HOUSING: Number of bedrooms in the home

HOUSING: Is the client at risk of homelessness?

HOUSING: Who lives in the client's home? What are their ages and what are their relationships to the client?

HEALTH: Does the client have any health conditions relevant to this referral, and if so what are they?

HEALTH: Does anyone in the client's household have any health condition relevant to this query, and if so what are they?

NATIONALITY / RIGHT TO RESIDE: What is the client's nationality?

NATIONALITY / RIGHT TO RESIDE: What is the client's right to live in the UK?

INCOME: What benefits does the client claim? (amount and frequency)

INCOME: What wage does the client earn? (amount and frequency)

INCOME: Does the client need a benefit check?

DEBT: Does the client have any debts? If so, how much and who do they owe it to?

EMPLOYMENT: What is the client's employment status?

EMPLOYMENT: Contract type

EMPLOYMENT: (If applicable) How long has the employer worked for their employer?

Thank you for your submission. We have received your referral and will schedule contact with the client to explore their issue(s). If the issue cannot be resolved at an initial exploratory stage we will schedule an appointment with the client to resolve their issue.

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