Make an Enquiry About Your Issue

This referral form will be sent to our team of advisers who will contact you within 5 working days of the form being submitted.

Please visit one of our branches if you have an emergency (such as an eviction notice) that is time sensitive.

If you are looking to refer a client or someone you work with to our services for support, please select the tab titled external agency referral and complete the form.

Self Referral
External Agency Referral

URL

This field is for validation purposes and should be left unchanged.

I Agree that as part of the referral process, Citizens Advice Bury & Bolton (CABB) will ask for some details about myself and the issue I am looking for help with. CABB will use this information to provide me with advice as well as to improve their service and inform their campaigns. More details about rights and how CABB use information can be found on the CABB privacy notice below; www.citizensadvice.org.uk/myinformation www.cabb.org.uk/privacy-policy/

Date Of Referral(Required)

DD slash MM slash YYYY

Personal Details

First Name(Required)

Surname(Required)

Date Of Birth (If unknown please put 01/01/1900)(Required)

DD slash MM slash YYYY

Address(Required)

Street Address City ZIP / Postal Code

Contact Details

Please fill out as much information as possible so we can contact you.

Mobile Phone Number(Required)

Home Phone Number

Email Address

Communication Preferences(Required)

Phone

Voicemail

Text

Postal Letter

Please state which communication method you would prefer we contact you

COMMUNICATION METHODS NOT TO BE USED

Please state any communication methods you DO NOT want us to contact you using this box

Support Required

Which Area/s Do You Need Help With? (Please tick the ones relevant to you)(Required)

Housing

Benefits

Community Care

Debt

Employment

Energy

Family

Immigration

Consumer

Other

Please Explain What You Need Help With(Required)

Please provide as much information as possible so we can route your enquiry through to the correct team.

Are you in receipt of universal credit?(Required)

Yes

Please let us know if you require any adjustments when you are contacted

Contact for Research and Feedback

We want to get feedback on the advice we provide. We will use this information to improve our service and inform our campaigns in a way that doesn’t identify you. If you want more detail about your rights and how we use your information you can read our privacy notice on our website.

Do Not Contact Me For Research and Feedback On

Phone

Voicemail

Text

Postal Letter

I agree to Citizens Advice selecting me for feedback using my information and contacting me

I Agree that as part of the referral process, Citizens Advice Bury & Bolton (CABB) will ask for some details about myself/the client and the issue they are looking for help with. CABB will use this information to provide me/the client with advice as well as to improve their service and inform their campaigns. More details about rights and how CABB use information can be found on the CABB privacy notice below; www.citizensadvice.org.uk/myinformation www.cabb.org.uk/privacy-policy/

Date Of Referral(Required)

DD slash MM slash YYYY

Referring Organisation Details

Name(Required)

First Last

Organisation(Required)

Address

Street Address City ZIP / Postal Code

Phone(Required)

Email(Required)

Client Consent

Has the client provided consent for this referral to be completed on their behalf?(Required)

Yes - I confirm the client has provided consent to this referral being completed on their behalf

Has the client provided consent for you (the referring organisation) to be updated on the case?(Required)

Yes - the client has provided consent for the referring organisation to be kept updated on the case

No - the client has not provided consent for the referring organisation to be kept updated on the case

Support Worker Details - if different from Referring Organisaton Details

Name Of Support Worker

First Last

Is The Support Worker Attending The Appointment With The Client?

Yes

Phone

Client Details

First Name(Required)

Surname(Required)

Date Of Birth (If unknown please put 01/01/1900)(Required)

DD slash MM slash YYYY

Address(Required)

Street Address City ZIP / Postal Code

Client Contact Details

Please fill out as much information as possible so we can contact you.

Mobile Phone Number(Required)

Home Phone Number

Email Address

Communication Preferences(Required)

Phone

Voicemail

Text

Postal Letter

Do Not Contact The Client On(Required)

Phone

Voicemail

Text

Postal Letter

Please note that at least 1 communication method is required to progress this referral.

Support Required

Which Area Does The Client Need Help With?(Required)

Housing

Benefits

Community Care

Debt

Employment

Energy

Family

Immigration

Consumer

Other

Please Explain What They Need Help With(Required)

Please provide as much information as possible so we can route the enquiry through to the correct team.

Is The Client In Receipt of Universal Credit?(Required)

Yes

Contact for Research and Feedback

We want to get feedback on the advice we provide. We will use this information to improve our service and inform our campaigns in a way that doesn’t identify the client. If they want more detail about their rights and how we use their information they can read our privacy notice on our website.

Do Not Contact The Client For Research and Feedback On

Phone

Voicemail

Text

Postal Letter

The client agrees to Citizens Advice selecting them for feedback using their information and contacting them