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Submitted by
user
on Fri, 2019-12-20 07:46
Client Consent
Yes
You have the right not to give consent, but in not doing so we will be unable to give you specific direct advice.
We need your explicit consent to use some information, including your ethnicity, religion, health conditions, sexual orientation, trade union membership and political opinion.
We are required by law to ask for your permission to record the details of your case.These details may contain your personal and sensitive data. The record of your case will be stored in a shared electronic case management system accessed by members of the CAB service.
By ticking the following boxes you are confirming the specific consents and authority!
Consent to Record and Use personal information
Yes
Consent to Share Information for collecting feedback
No
Yes
Please tick all that are appropriate
Mobile
Call
Voicemail
Text
Email
Yes
Home Telephone
Call
Voicemail
Home Address
Yes
I agree to be contacted about my Advice Query
No
Yes
Mobile
Call
Voicemail
Text
Email
Yes
Home Telephone
Call
Voicemail
Ethnicity
Yes
Home Address
Yes
Health Condition
Yes
Religion
Yes
Sexual Orientation
Yes
Trade Union Membership
Yes
We may be asked to share your contact details if you have been in close contact with someone has coronavirus. Please tick if you do NOT wish to share these
Test and Trace - sharing your contact details
No
Yes
Title
Mr/Ms/Other (please state)
Forename
Surname
House name/number
Post Code
*
Date of Birth
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
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1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Gender
*
Prefer not to Say
Male
Female
Other
Ethnicity
*
Prefer not to Say
White British
White English
White Scottish
White Welsh
White Northern Irish
White Irish
White Gypsy or Irish Traveller
White Other
Mixed - White & Black Caribbean
Mixed - White & Black African
Mixed - White & Black Asian
Mixed - Other
Asian or Asian British - Bangladeshi
Asian or British - Chinese
Asian or Britsh - Indian
Asian or British - Pakistani
Asian or British - Other
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other
Other - Arab
Any Other
Unknown
Any Disabilities (Please Specify)
Tel/Mobile No
Email Address
*
Nature of Enquiry
Benefits
Employment
Tax
Debt/Money Management
Family & Relationships
Health
Home & Neighborhood
Education
Consumer
Gas & Electricity
Discrimination
You may choose multiple items
Further Information (Please ensure as much information as possible is entered)
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