Self-ReferralSelf-Referral

Thank you for your interest in our services.
Please complete the form below and press submit when you have completed it.
Someone will respond to the referral as soon as possible.

Filling out the form

  • Please note that the coordinator will need a working telephone number and email address with which to contact you. It may take up to 3 working days to reply.
  • Please also disclose whether you have any contact requirements e.g. not wanting to be contacted via phone, not wanting to have messages left or whether you wish to only be contacted via email.
  • Fields marked * are required fields.

By filling out this form you agree that your information will be forwarded to a Citizens Advice co-ordinator.

    Apologies, we are experiencing some technical difficulties at the moment. If you need to contact us please email us at:

    enquiries@chelmsfordcab.org

    Self-Referral form

    Your details: *

    Address: *

    Date of birth: *

     

    Contact details:

     

    Preferred methods of contact:

    MobileHomeOtherEmail

    Do NOT contact me by:

    MobileHomeOtherEmail

    Gender: *

    FemaleMaleOtherPrefer not to say

    Your problem: *

    Do you have any documents to upload:

    Acceptable file types...
    DOC, DOCX
    GIF, JPG, JPEG, PNG
    PDF, TXT
    Max file size = 1Mb.

    Consent to record data above: *

    When we record and use clients 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.

     

    Do you agree for us to record this data? * YesNo

     

    Email security

    Whilst every effort is made to ensure the security and integrity of your personal information no data transmission over the internet can be guaranteed 100% secure. Email traffic is in unencrypted plain text format however it is extremely unlikely that unauthorised people will intercept your email. If you are worried about confidentiality then please contact us by phone or in person.

    If you are concerned about other people having access to your email account at home or at work, you may wish to set up a separate personal web-based email account.

    Disclaimer

    The advice and information contained in our email replies gives only general guidance. It should not be regarded or relied upon as a complete or authoritative statement of law.