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Help to Claim Referral Form

This referral will be sent directly to the Help to Claim service.

Name of referring organisation and department
Name of staff member making this referral
Has the client given verbal consent for their details to be passed to Citizens Advice LeicesterShire to allow us to contact them?
Has the client given verbal consent for Citizens Advice LeicesterShire to discuss their case fully with the referring organisation?
Citizens Advice Leicestershire processes information provided on-line, which includes your personal information, and stores this securely on a shared electronic management system accessed by members of the Citizens Advice Service. Personal information is any information which can identify you. e.g. name, address, date of birth etc. By completing and submitting this online form, you are providing consent for your personal information to be stored. If you do not wish your details to be held, please contact our telephone service on 0808 2787854. Special category data includes the following: personal data revealing racial or ethnic origin; political opinions; religious or philosophical beliefs; trade union membership; data concerning health; data concerning a sexual orientation. You may submit this form without consenting to special category data being stored, but this may affect our ability to provide you with the most appropriate advice possible.
Please use this space to give any further information about the issue, including any action already taken, any deadlines or other relevant information