Email Advice

In order for us to help with your enquiry we will need to record your personal information and the details of your case. In providing these details you give your consent for us to store a record of your case in a shared electronic case management system accessed by members of the Citizens Advice service. All information supplied by you is strictly confidential.*

I give my consent to the Citizens Advice service recording sensitive personal information about me.

Full Name*

Email*

Confirm Email*

Can we contact you by phone?*

For Foodbank Referrals, please provide your preferred telephone number, as we will need to contact you to discuss

---YesNo

Phone Number*

Can we use voicemail or text?*
---YesVoicemail onlyText onlyNo

Date of Birth*

Full address and postcode*

Gender*
---MaleFemalePrefer another termPrefer not to say

What term do you prefer?*

Ethnicity*
---White BritishWhite IrishWhite OtherBlack or Black BritishBlack CaribbeanBlack AfricanAsian or Asian BritishAsian IndianAsian PakistaniAsian BangladeshiChineseMixedMixed White and Black CaribbeanMixed White and Black AfricanPrefer not to say

Are you a disabled person and/or have a long term health condition?*
---YesNoPrefer not to say

Please tell us how we can help*