We need your explicit consent to record some special category information that you might provide to us, including your ethnicity, heath conditions, trade union membership etc. If you agree, we’ll use this information to give you advice, help us to gather data, research and improve our service. We will make sure this information is kept safe and secure.
Please tick the boxes if you agree to Citizens Advice recording the special category personal data
I agree to the Citizens Advice service sharing my personal information with organisations so that I can be contacted to give feedback about my experience with Citizens Advice
Please select the ways that we can contact you:
Date of birth
First line of address
Can this address be used to contact you by post?
Please provide an email you are happy to be contacted on
Can we leave a message on your mobile?
Can we leave a message on your home phone?
Can we leave a message on your work phone?
Can we contact you by text message?
Please select 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 & Asian Mixed - Other Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Other Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Other - Arab Other - Any other Unknown Prefer not to say
Can you tell us about your health issue?
Further Details (not mandatory)
Single person Single with dependent children Single with non-dependent children Couple Couple with dependent children Couple with non-dependent children Other adults only Other adults and dependent children Other adults with non-dependent children Prefer not to say
Own outright Buying home (mortgage) Shared ownership Council/ALMO tenant Housing Association/RSL tenant Private tenant Housed through job/business Staying with relatives/friends (rent free) Staying with relatives/friends (paying rent) Hostel Prison Homeless (incl. B&B tenant) Residential accommodation (nursing/care home) Other Prefer not to say
Employed more than 30 hrs/week Employed less than 16 hrs/week Employed 16-29 hrs/week Unemployed - seeking paid employment Volunteer Retired Semi-retired Student Govt scheme for employment Carer - elderly/disabled Carer - children Looking after home - no dependents Looking after home - dependents Permanently sick/disabled Temporarily sick Other Self employed Casual / seasonal work Prefer not to say
National Insurance Number
Bisexual Gay man Gay woman/Lesbian Heterosexual/Straight Prefer not to say
Single Married/cohabiting/civil partnership (to Sept 2013) Separated but legally married/CP Divorced/CP dissolved Widow / surviving CP partner Married Cohabiting Civil partnership (post Sept 2013) Prefer not to say
No religion Christian (any denomination) Christian (Catholic) Christian (Protestant) Buddhist Hindu Jewish Muslim Sikh Any other religion Prefer not to say
First language (if not English)
Is an interpreter required?
How can we help?
Please tell us about your problem or issue
0 of 500 max words
What have you already done about your problem or issue?
0 of 500 max words
Please upload any relevant images or document here (up to 5 uploads)