Make a referral

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Please complete this form to make a referral to Citizens Advice Copeland. We only accept referrals from external agencies through our website.

If you would like advice please call 0808 278 7959 or email advice@cacopeland.org, there is also lots of information in the Get Advice section of our website.

Referrers Name *

First

Last

Referrers organisation *

Referrers email *

Referrers contact number *

What does the client require help with? *

Debt e.g. rent/mortgage arrears, council tax arrears, fuel arrears, credit cards, loans, catalogues, etc, Breathing Space, Benefits eg benefit forms, benefit check, benefit appeal, Housing eg eviction, disrepair, Notice Seeking Possession/Court Action, support to gain or maintain a tenancy, Grants/Hardship support for white goods, furniture, gas, electric

Has the client been referred to another agency? If so, what assistance are they providing? *

Please confirm that the client gives permission for their information, confidential or otherwise, regarding their case which may contain sensitive personal data to be shared electronically with Citizens Advice Copeland: *

Yes, the client is happy for their information to be shared electronically with Citizens Advice Copeland
No, the client is NOT happy for their information to be shared electronically with Citizens Advice Copeland

Please confirm that the client gives permission for Citizens Advice Copeland to discuss their case with the referring agency: *

Yes, the client gives permission for Citizens Advice Copeland to discuss their case with the referring agency
No, the client does NOT give permission for Citizens Advice Copeland to discuss their case with the referring agency

Client's Name *

First

Last

Clients DOB *

Clients Mobile Number *

Please note that calls made to clients will be from an unknown or withheld number. We will attempt to contact the client on three occasions. If we are unable to get through to the client after three attempts their case will be closed.

Clients Home Phone Number

Clients email

Does the client give permission for Citizens Advice Copeland to:

Leave a voicemail
Send an SMS
Send a letter
Send an email

Clients Address & Postcode *

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