Peňažná poradenská služba

Please check if you DO NOT want us to record any of the following special category data: Please check if you DO NOT want us to record any of the following special category data: Details of disability/health condition Religion Etnicita Sexual Orientation Trade Union Membership I DO NOT want ANY of the special category data to be recorded

Have you contacted Citizens Advice previously? Have you contacted Citizens Advice previously? Áno Nie

Through which service? Through which service? Online In person Telephone Iné

Do you have ongoing access to the internet? Do you have ongoing access to the internet? Áno Nie

If no, could you explain why?

Are you confident in dealing with letters and forms independently? Are you confident in dealing with letters and forms independently? Áno Nie To some extent

Full name:

Dátum narodenia

Full address:

Contact number:

Email address:

Preferred method of contact: Preferred method of contact: Post Phone Email

10. Do you have any physical or mental health issues we need to be aware of 10. Do you have any physical or mental health issues we need to be aware of Áno Nie

Please provide more information

Do you have any disabilities that would restrict access to the service? Do you have any disabilities that would restrict access to the service? Áno Nie

Please provide more information

Is English your first language? Is English your first language? Áno Nie

Do you require an interpreter? Do you require an interpreter? Áno Nie

Which language do you require?

Are you self employed? Are you self employed? Áno Nie

Please advise us of your total income

Please advise us on your living situation (rental, mortgage etc)

Are there any dependants living in the property with you?

Are there any dependants who do not live with you?

Are you subject to any enforcement action that will take place in the next 5 working days i.e threat of eviction, bailiff action, fuel disconnection, court action etc?

Have you lost contact with any of your creditors for 6 years or longer? Have you lost contact with any of your creditors for 6 years or longer? Áno Nie

Have you received debt advice before? Have you received debt advice before? Áno Nie

Please provide details

How much debt do you have? Please list the amount and company where possible

Do you dispute any of the money owed? Do you dispute any of the money owed? Áno Nie

Do you need help to identify any benefits or grants you may be entitled to? Do you need help to identify any benefits or grants you may be entitled to? Áno Nie

Is there anything else you need advice on?