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Make a Referral

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 01946 693321 or email advice@cacopeland.org, there is also lots of information in the Get Advice section of our website.

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

Unfortunately, you can not submit this form unless the client has confirmed that they are 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

Referrers Name *

First

Last

Referrers organisation *

Referrers email *

Referrers contact number *

Are you a member of the West Cumbria Mental Health Partnership?

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

Does the client have any threats of eviction, bailiffs or disconnection of gas or electric supply? *

Please give as much detail as possible and include any dates for required action.

Hardship support; How much food have they got? What is the reason for their hardship? When do they next get paid?

For fuel vouchers the client will need to provide photos of their meter and proof of ID (which can be photo ID or a letter with their name and address on)

If the client requires debt advice do they have any letters from court for eviction, council tax, utilities or any bailiff action? Is there a date for any required action? Is the client able to provide details of how much they owe when we contact them?

Does the client require help with a benefit form? If so, do they have the form? What form is needing completed? When is the return date?

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

Client's Name *

First

Last

Clients DOB *

Clients Mobile Number *

Please note that calls made to clients will be from an unknown, withheld number or 0808 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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