KPA Referral - Citizens Advice Exeter

Does Citizens Advice have consent to record the information you are providing? *

Yes

No

Client Name *

Date of Birth

Post Code *

First Line of Address *

Does Citizens Advice have permission to write letters to Client? *

Yes

No

Email Address *

Only include if client has consented to Citizens Advice sending emails – if client refuses permission or does not have an email address write NONE

Primary Telephone Number *

Does Citizens Advice have permission to leave messages on the Primary Telephone number? *

Yes

No

Alternative Number

Does Citizens Advice have permission to leave messages on the Alternative Telephone number?

Yes

No

Does Citizens Advice have permission to send text messages? *

Yes

No

Details of any restrictions (For example, only phone on Mondays)

What help does the client need?

Name and contact details of the person making this referral if other than the EDKPA Secretary

Referral Officer Email Address *