Email – CA Elmbridge

We will ask you for some details about yourself and the issue/s you are looking for help with. We will use this information to provide you with advice as well as to improve our service, inform our campaigns and help us ensure that we are delivering our service in a way that supports everyone and that we are reaching people from all backgrounds. I give permission to Citizens Advice to record the personal information that will be given below *

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If you want more detail about how we use your information you can read the privacy notice on our website. Please click here.

I agree to the Citizens Advice service sharing my personal information with organisations so that I can be contacted to give feedback. *

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I give my permission to Citizens Advice sharing my personal information with other advice providers for the purposes of efficient appointments and referrals to help me with my case *

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I agree with the Citizens Advice client agreement *

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View Client Agreement here

You have selected no and therefore do not give your consent to Citizens Advice to hold your personal information, you will therefore not be able to submit this form.

You have selected no and therefore do not agree to the Citizens Advice Client Agreement, you will therefore not be able to submit this form.

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First Name *

Surname *

Date of Birth *

Marital Status (please select)

Partner's name (if relevant)

Ethnicity (please select)

Gender (please select)

Nationality (please state)

Language (please confirm first language if not English)

Do you need an interpreter?

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Address *

Postcode *

Can we write to you at this address? *

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Email

Can the email address be used to contact you? *

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Mobile Phone

Home Phone

Can we leave a voice message? *

Mobile phone

Home phone

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Can we send an SMS? *

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What is your preferred contact method for advice?

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Health details - disabled, long term health condition or access needs (please select)

Details of health condition (please select)

Household Type (please select)

Housing Type (please select)

Employment Status (please select)

National Insurance Number

Please tell us briefly about your problem or issue *

Please upload any relevant images or document files

Maximum file size: 516MB

Please let us know how you found out about our online referral form *

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Everything you tell us will be treated in absolute confidence and all records are stored securely. See our Privacy Policy for more information.

Please complete the referral form below and an advisor will contact you.

Referral Form

If you want more detail about how we use your information you can read the privacy notice on our website. Please click here.

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