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Client Referral Form (DA Project)

Citizens Advice is closing face-to-face drop-in sessions/appointments in Cornwall in response to the national coronavirus outbreak. We are however, still providing telephone advice.

Please do not add any GDPR special category data (SCD) to this referral as we need explicit consent direct from you, the client, to store this data. SCD= ethnicity, health condition, mental health condition, religion, sexuality, trade union membership

Do you, the client give consent to Citizens Advice Cornwall to contact you and store personal information data? (required)

What is your main enquiry about (e.g. debt, housing, employment, welfare benefits or anything else?) (required)

Is this a referral to the Domestic Abuse Project? (required)

Please provide your full name (required)

Address (required)

Date of Birth

National Insurance No.

Gender

Please give a brief outline as to your enquiry and the outcome you hope to achieve(required)

Are there any urgent or deadline dates you can tell us about in relation to your enquiry?

Do we have permission to send written information to your home address? (required)

Your Landline Phone number

May we phone your landline in order to contact you? YesNo

If applicable, please state a preferred time when it is safe or convenient to call

May we leave a voice message on your Landline? YesNo

Your Mobile Phone number

May we phone your mobile in order to contact you? YesNo

If applicable, please state a preferred time when it is safe or convenient to call

May we leave a voice message on your mobile? YesNo

May we send a text message to your mobile? YesNo

Your email address

May we contact you via email? YesNo

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