Crisis and Resilience Fund Enquiry Form CRF Enquiry Title Name * First Surname * Surname Date of Birth * Address * Post Code * Email address * Confirm Email address * Contact number * Please select which additional methods of communication you are happy with: * Voicemail SMS Letter Depending on your query, it may be better for us to call you about your situation. Are you happy for us to do this? * Yes No Can we contact you for feedback about our service? * Yes No Please select how we can contact you for feedback: * Mobile Number Home Number Work Number Email Letter Voicemail SMS What do you need advice about? * Please upload any relevant images or document files Drop a file here or click to upload Choose File Maximum file size: 516MB We ask our clients if they are happy to share some information about their background with us. You don’t have to provide us with this information and it does not affect the advice you receive. However, it helps us ensure that we are delivering our service in a way that supports everyone and that we are reaching people from all backgrounds. Gender Please selectManNon-binary, gender fluid or gender queerWomanPrefer a different term (other)Prefer not to say Do you identify as transgender? Please selectYesNoPrefer not to say Your Sexual Orientation Please selectAsexualBisexual/pansexualGay or lesbianGay or lesbianHeterosexual or straightPrefer not to say Nationality Ethnicity Please selectArabAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - OtherAsian or Asian British - PakistaniBlack or Black British - AfricanBlack or Black British - CaribbeanBlack or Black British - OtherMixed - OtherMixed - White & AsianMixed - White & Black AfricanMixed - White & Black CaribbeanRomaWhite - English, Welsh, Scottish, Northern Irish or BritishWhite - Gypsy or Irish TravellerWhite - IrishWhite - OtherPrefer not to say Do you have a Disability, Long-Term Health Condition or any Access Needs? * Yes No Prefer not to say Impairment, condition or access needs (select as many as applicable) * Chronic or long term pain Chronic or long-term condition Dexterity (handling or using objects) Hearing Hearing Learning, understanding or concentrating Memory Mental health Mobility (moving around) Neurodivergence (including autism, social or behavioural differences or ADHD) Neurodivergence (including autism, social or behavioural differences or ADHD) Neurological condition (including epilepsy) Speech or language Stamina, breathing or fatigue Vision None of these describe my impairment, condition or access need Marital Status (select one) * Single Married Civil Partnership Cohabiting Divorced/Civil Partnership dissolved Widowed/Surviving Civil Partner Separated but legally married/civil partnership Prefer not to say Household Type (select one) * Single Person Single Person with Dependent Children Single Person with Non-Dependent Children Couple Couple with Dependent Children Couple with Non-Dependent Children Other – Adults only Other – Adults & Dependent Children Other – Adults & Non-Dependent Children Prefer not to say Number in Household Children over 14 Children under 14 Housing Type * Own Outright (no mortgage) Buying Home (with Mortgage) Shared Ownership Council Tenant Housing Association Tenant Private Tenant Housed Through Job Staying with friends/relatives - rent free Staying with friend/relatives - paying rent Hostel Prison Homeless Residential Accommodation Other Employment Status (select one) * Employed working 30 hours or more per week Employed working between 16 and 30 hours per week Employed working less than 16 hours per week Unemployed looking for work Volunteer Retired Semi-retired Student Government Training Scheme Carer for Elderly/Disabled Carer for Children Looking after home – No dependents Looking after home – Dependents Permanently Sick/Disabled Self Employed Other Prefer not to say Monthly Household Income - including Benefits (select one) Less than £400 £400 - £599 £600 - £799 £800 - £999 £1000 - £1299 £1300 - £1499 £1500 - £1999 £2000 - £2499 £2500 - £2999 More than £3000 What is the sudden, unexpected financial issue that has caused you unexpected financial difficulties? * Disaster Accident or Health emergency Household relationship breakdown Essential item breakdown Unexpected loss of income OtherOther What has this left you in need of and unable to afford? * Food Essential item/ Wider essentials Furniture/appliances Rent/housing crisis Essential transport Priority debt/bill crisis Essential utilities OtherOther Can you tell us exactly what you are in need of? * How much will this cost? * £0 - £50 £50 - £100 £100 - £150 £150+ Please specify the amount Captcha Submit If you are human, leave this field blank.
