NEA Benefits Advice referral form 1Referrer Details2Client Details3Other information We can assist with Income Maximisation Advice such as benefit checks and form filling (i.e. Personal Independence Payments, Attendance Allowance, Disability Living Allowance etc), we are not able to support clients with appeals or mandatory reconsiderations.Referrer's detailsName(Required) Forename Surname Job title Organisation(Required) Telephone number(Required)Email address(Required) Enter Email Confirm Email Client's detailsClient's name(Required) Forename Surname Client's address(Required) Street Address Address Line 2 City County ZIP / Postal Code Client's telephone number(Required)Can a message be left on this number? Yes No Client's mobile number(Required)Can a message be left on this number? Yes No Client's email address (if they have one) Enter Email Confirm Email Client's date of birth(Required) DD slash MM slash YYYY Interpreting Service Required Yes No Customers Preferred Spoken LanguageAfrican – OtherArabicBengaliChineseEnglishFarsiFrenchGaelicGermanGujeratiHindiKurdishOtherPakistaniPashtunPolishPunjabiRomanianSign LanguageSomaliSpanishTurkishUrduVietnameseWelsh Other informationPlease include information about the issue, any progress or actions already taken, any known deadlines or any sensitive matters to be aware of.(Required)You can upload any relevant supporting information here.Max. file size: 10 MB.Consent(Required) By ticking this box you confirm that: The client has given their permission for you to pass their information on to NEA. You have explained the purpose of doing so and made the client aware that their information will be used by a member of the team to contact them. You are processing the client’s data lawfully. You are aware your personal details will be kept by NEA for the purposes of completing this referral. Any information you supply will be stored and processed according to NEA’s Privacy Notice. Consent(Required) Please tick this box to confirm your understanding of the above
