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Supporting Leicester and Leicestershire since 1979

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Make A Referral
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MAKE A REFERRAL

Please complete the form below, providing us with as much information as possible to assess how we are best able to support you.

Referral Form

Once we have received and processed your referral, one of our team will be in touch to discuss how we may be able to help.

Please note that in some instances, we may need to contact you to complete an initial assessment and collect further details to establish if we can help you. This process is most quickly completed via telephone.

Your Details

Click on this text to edit it.

Please leave blank:

Full Name:

Town:

Date of Birth (Optional):

Email:

Address:

Postcode:

Gender:

Telephone:

How did you hear about us:

Contact Preferences

Please use the boxes below to indicate your consent and preference for how our team contact you:

Can we contact you by phone?

Can we contact you via SMS?

Can we contact you by email?

Can we contact you by post?

Can we leave a voicemail message if we are unable to get hold of you?

Preferred method of contact:

Preferred time of contact:

Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM

Support required (please tick all that apply)

Money and Debt

Tick if applicable:

Council tax arrears Rent /Mortgage arrears Secured Loan Arrears Court fines Benefits Overpayments PCN/Parking Fines Utility Arrears (Gas/Electric/Telecoms) TV licence Arrears Hire Purchase Arrears Unpaid Tax, National Insurance or VAT Child maintenance arrears Other debts or arrears

Housing

Tick if applicable:

Suspension of Warrant Possession- Section 21 Notice/ Accelerated Claim Possession- (Anti-social behaviour or other) Homelessness Property Disrepair Rehousing Issues (Including banding, overcrowding and medical reason issues)

Rent Arrears:

Housing Association Local Authority Private Landlord Other

Immigration

Please select from the drop-down menu and provide additional details:

Secondary Issue:

Welfare Benefits

Tick if applicable:

Challenging a Universal Credit (UC) Decision Challenging an Employment & Support Allowance (ESA) Decision Challenging a Housing Benefit (HB) Decision Challenging a Council Tax Support (CTS) Decision Challenging Personal Independence Payment (PIP) Decision Disability Living Allowance (DLA) Issue Child Benefit (CB) /Pension Credit (PC) /Working Tax Credit (WTC) Issue

Do you also need help with any of the following?

Money/Debt Housing Immigration Welfare Benefits Energy

How urgent is it?

If there's a deadline, or hearing daye, what is it?

Do you need an interpreter?

First language:

Any access needs or adjustments?

Need help filling this in? You can ask a family member or support worker to complete it with you, just tell us below.

I'm filling this in on some else's behalf.

Data Protection and Privacy

We use the information you give us only to provide advice and to contact you about it. We keep it securely and do not share it without your permission, except where we must by law. You can ask to see, correct or delete your information at any time. Full details are in our Privacy Notice.

Contact Request:

I agree to LCALC holding and using my information to give me advice and contact me about it.

© 2025 Copyright Community Advice and Law Service Ltd. Trading as Leicester Community Advice and Law Centre. All Rights Reserved. Registered Company Limited by Guarantee 04096574. Registered Charity Number 1087214.

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Welfare Benefits Advice