12IS IT AN EMERGENCY?If you or someone else are in immediate danger, call 999 now.IS THIS A REFERRAL?If you are a professional completing this form on behalf of a client, please use the referrals form: https://www.ukeff.org/referrals/Your DetailsName *FirstLastAddress *Address Line 1CityState / Province / RegionPostal CodeIf rough-sleeper or homeless, please provide hostel details or other contact pointPhone Number *Date of Birth *Email *EmailConfirm EmailGender *MaleFemaleOtherMarital Status *SingleMarriedDivorcedSeparatedWidowedCivil PartnershipLiving with partnerIs your spouse in the UK? *YesNoEthnicity *Religion *Main Language *Interpreter needed? *YesNoNextThe People you Live WithNumber of adults in your home *123456789Adults are anyone aged 18 years and overNumber of children in your home *012345678How Can We Help?Are you having any of these problems?Food billsEnergy billsFinancial hardshipBenefitsHousingDomestic abuseDebtCourt/policeSubstance abuseAlcohol abusePhysical healthMental healthPlease select any that apply to your current application for helpPlease provide FULL DETAILS of your current situation & assistance required *File UploadPlease upload any documents to support your application. E.g. bank statements, bills, eviction notices. Please note that without supporting evidence, your application will be delayed and may be refused.Did you have any help to complete this form? *YesNoName of person who helped you *FirstLastAddress of person who helped you *Address Line 1CityState / Province / RegionPhone number of person who helped you *Email of person who helped you *Data Protection and Confidentiality *I have read and give my consent to the statement below.I give my consent to UKeff to collect, use and store the personal information held about me in this form for the purpose of assisting me. I also consent for UKeff to contact me directly to offer support and assistance and to maintain future contact if the need arises. [The information you submit will be kept in accordance with the Data Protection Act 1998. UKeff is committed to equal opportunities and seeks to assist individuals from all sectors of the community. UKeff will not tolerate the less favourable treatment of anyone on the grounds of their gender, age, race, colour, nationality, ethnic or national origin, disability, marital status, sexual orientation, responsibility for dependents, trade union or political activities, religious or other beliefs, or any other reason which cannot be shown to be justified. This policy is subject to the requirements and legislative framework as outlined in the Equality Act 2010.]CommentSubmit
