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HELP APPLICATION FORM
If you are a professional completing this form on behalf of a client, please use the referrals form:
Click Here
1
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IS IT AN EMERGENCY?
If you or someone else are in immediate danger, call 999 now.
Your Details
Name
*
First
Last
Address
*
Address Line 1
City
State / Province / Region
Postal Code
If rough-sleeper or homeless, please provide hostel details or other contact point
Phone Number
*
Date of Birth
*
Email
*
Email
Confirm Email
Gender
*
Male
Female
Other
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Civil Partnership
Living with partner
Is your spouse in the UK?
*
Yes
No
Ethnicity
*
Religion
*
Main Language
*
Interpreter needed?
*
Yes
No
Next
The People you Live With
Number of adults in your home
*
1
2
3
4
5
6
7
8
9
Adults are anyone aged 18 years and over
Number of children in your home
*
0
1
2
3
4
5
6
7
8
How Can We Help?
Are you having any of these problems?
Food bills
Energy bills
Financial hardship
Benefits
Housing
Domestic abuse
Debt
Court/police
Substance abuse
Alcohol abuse
Physical health
Mental health
Please select any that apply to your current application for help
Please provide FULL DETAILS of your current situation & assistance required
*
File Upload
Please 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?
*
Yes
No
Name of person who helped you
*
First
Last
Address of person who helped you
*
Address Line 1
City
State / Province / Region
Phone 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.]
Name
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