Thank you for contacting Richmond AID about your query.

If you need help with completing your query please contact us on 020 3393 7011. Please see our privacy statement at the end of this form.

I give my permission for Richmond AID to keep my personal information*

Please tell us what support you need. Please give as much details as possible. Please tell us if you have any important deadlines that we need to be aware of (e.g. benefits forms, evictions).

Where did you hear about us?

Have you contacted us before?

Your Title (Mr, Ms, Mrs, Dr)

Your first name(s)*

Your surname*

Address line 1*

Address line 2

Address line 4 (Town)*

Address line 5 (County)

Postcode*

Mobile Telephone No.

Home Telephone No.

Emergency Telephone No.

Email Address (Main)*

Main Disability*

Date of Birth

Gender

Immigration status

Ethnic Group

Religious Group

Marital Status

Sexual Orientation

Tell us your communication needs

Please tell us what language translation you need

How would you like us to contact you?

Tell us about your housing?

How many people are in your household?

Are you a disabled person living with an unpaid carer?

Are you employed? (Benefit clients only)

National Insurance Number (for benefits clients)

Social care arrangements

Name of your GP practice

Privacy statement

We ask for your personal information so we can help you and we record it on our database. We will treat is as confidential and only share with other organisations with your consent.

You can withdraw your consent to be on our database or have your information updated at any time (call 020 8831 6070 or email advice@richmondaid.org.uk ). You can stay anonymous and we'll record information about your problem making sure you're not identified, but this may impact how well we can support you. Third parties such as the assessors of the Advice Quality Standard may require access to client records for quality auditing purposes. You have the right to opt out from this process if you wish.

For more information about how we manage data please see our Privacy Notice on the Richmond AID website www.richmondaid.org.uk