Request edit access
Contact Information
Sign in to Google to save your progress. Learn more
Email *
This service is not suitable for emergencies or impending deadlines.
Have you used the Citizens Advice Leeds before? *
The record of your case will be stored in a shared electronic case management system accessed by members of the Citizens Advice Service. We follow nationally agreed policies on client confidentiality and data protection. We will not voluntarily share information about you with anyone unless you give us permission. It is very important that you give us permission to store your information otherwise your query cannot be processed. When we record and use your personal information we: ● only access it when we have a good reason ● only share what is necessary and relevant ● don’t sell it to commercial organisations We need to record information about you to help with your enquiry. We have a legitimate interest to do this. If you’d like more information about how we’ll use your data please read our Privacy Policy at
Please tick to consent to your data being stored *
We need your consent to record and use your special category personal data
We need your explicit consent to use some information, including your ethnicity, religion, health conditions, sexual orientation, trade union membership and political opinion.
If you agree, we’ll use this information, which is known as ‘special category personal data’ to:
● give you advice
● help us gather data to improve our service
● support our research in a way that you can’t be identified
We’ll make sure all your information is kept safe in our secure case management system.
By ticking the boxes below you consent to Citizens Advice recording the special category personal data you choose to provide Citizens Advice.
Do you consent to us holding information on your Ethnicity? *
Do you consent to us holding information on your Religion? *
Do you consent to us holding information on your Health Condition? *
Do you consent to us holding information on your Sexual Orientation? *
Do you consent to us holding information on your Trade Union Membership? *
First name *
Last name *
Date of birth
Address *
Postcode *
May we send you a letter? *
National insurance number
Contact phone number (if we call you, it will be from a withheld number) *
Is it ok to leave a message? *
Do you have any disabilities or long term illness? *
Please tell us your Nationality, as the rules can be different for people who are not British Citizens *
There is legal protection if you are treated unfairly because of your race, gender, disability, sexual orientation, age, religion or belief. Do you think this might apply to your situation?
Clear selection
What is your ethnic origin?
Do you live with a partner?
Clear selection
Do you have any dependent children?
Clear selection
If yes, what are their ages?
Are you currently employed?
Clear selection
Do you receive any benefits?
Clear selection
How much income do you (and your partner if applicable) receive per month? Give approximate figures if you do not know exactly, include all wages and benefits
Where do you live? e.g. mortgaged property, council property, private tenant, housing association, staying with friends/relatives
Do you have any capital, savings, other properties that are not your main home?
Clear selection
If yes, please give details
How are you hoping we can help you? Please give as much detail as possible *
What have you done so far?
If we are at capacity we may ask our telephone service to contact you rather than replying by email. Is this OK? *
We will use the details that you have provided to send you relevant information to help solve your enquiry. If further advice is needed we may offer you an appointment at Citizens Advice Leeds and/or send you details of other organisations who can help. *
We want to make sure our service meets your needs. To help us understand how we’re doing and to improve our service, we may want to contact you at a later date to ask for your feedback. Sometimes we need a trusted research organisation to help us do that. We’ll decide who we contact for feedback based on the services you used and the advice area. We may also use your special category data so that we hear from different groups. Please tick the box below if you agree to us getting in touch. *
If we email you to offer you a face–to–face appointment, you must reply to confirm your attendance within two days. If you do not, we will offer the appointment to another client
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Citizens Advice Leeds. Report Abuse