RCN Lamplight Support Service: Pre-appointment questionnaire

Please complete the form below and ensure that you have details of your essential expenditure, such as mortgage and utilities, to hand at the time of your appointment.

Please click here if you experience technical difficulties with this form

If you experience any technical issues with this form, please contact the Lamplight Support Service at lamplight@rcn.org.uk

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Lamplight pre-appointment questionnaire

Fill out this form ahead of your appointment. All the information you provide is treated confidentially. Only complete this form after you've booked an appointment with the Lamplight team.

Section 1: About you and your circumstances

Date of appointment

If you do not have an appointment booked, please type TBC

First name Surname RCN membership number Email Phone number What circumstances have prompted you to contact Lamplight for support? What type of support are you hoping to get from Lamplight?

Section 2: Your household

What best describes your living situation? (please select one) Who else lives in your household (tick all that apply) Just me Partner Children Adult family member Lodger Other If you have stated that children live with you, please list their ages and genders How many bedrooms do you have? Is anyone in your household unwell or disabled? If so, please give details

Section 3: Your income (earnings)

Do you currently have any earnings from employment? (please select one) How many hours a week do you work? How much are your monthly earnings after deductions? (net pay)

Section 4: Your income (savings, capital and other)

Do you have any savings or capital? If so, please enter the approximate value(s)

An example of capital could be a property you don't live in.

Do you have any other income other than salary or benefits? If so, how much and from what source?

Other income sources could include maintenance for children, or an occupational pension

Section 5: Your income (benefits)

Please enter the monthly amount of any benefits you receive

Council tax support Child benefit Disability Living Allowance (DLA) Employment and Support Allowance Housing Benefit Jobseeker's Allowance Personal Independence Payment (PIP) State pension Tax credits Universal Credit Other benefit

Section 6: Your partner's income (earnings)

If you do not have a partner living with you, or your partner does not work, then you do not need to complete this section.

How many hours a week does your partner work? How much are your partner’s monthly earnings after deductions?

Section 7: Your partner's income (benefits)

Please enter the amount of any benefits your partner is receiving

Council tax support Child benefit Disability Living Allowance (DLA) Employment and Support Allowance Housing benefit Jobseeker's allowance Personal Independence Payment (PIP) State pension Tax credits Universal credit Other benefit

Section 8: Your partner's income (savings, capital and other)

Does your partner have any savings or capital? If yes, please enter the value

An example of capital could be a property they don't live in.

Does your partner have any other income other than salary and benefits? If so, how much and from what source?

(e.g. occupational pension, or maintenance)

Section 9: Expenditure

Please enter your monthly expenditure on the following items

Housing costs

(e.g. rent, mortgage, board, etc. Please tell us the amount stated on your contract or agreement. If you’re currently paying a different amount because of benefits or arrears, please tell us the original, contractual figure, not the amount you actually pay.)

Council tax

(Ignore any benefit you may receive towards this)

Gas and electricity

(Do not include payments towards arrears.)

Water

(Do not include payments towards arrears.)

Buildings and contents insurance Telephone and internet Mobile Childcare costs

(e.g. nursery, registered child minders or childcare provided through school.)

Child maintenance

(for children not living with you)

Costs for care or home help needed by you or your partner

(due to ill health or disability)

Essential public transport costs

(Please exclude fuel costs)

Road tax and insurance for your primary household vehicle

(Please exclude fuel costs)

Please list any debts you may have and how much you pay towards them each month. This may include credit cards, personal loans, store cards, arrears for council tax and utilities.

Debts

We appreciate these won't be your only costs. Please have figures for costs not included above to hand at the time of your appointment. You don't need to add them in to the above sections.

By submitting this form, you are giving the RCN permission to contact you about your submission.

You can control the information you receive from the RCN by updating your preferences at MyRCN.

The information you provide in this form will be stored by the RCN.

Protecting your privacy is very important to us. Please view our privacy policy to find out more about the information we collect and how it is used.

Join the RCN

Lamplight pre-appointment questionnaire

Please complete the form below and ensure that you have details of your essential expenditure, such as mortgage and utilities, to hand at the time of your appointment.

Please click here if you experience technical difficulties with this form

Lamplight pre-appointment questionnaire

Section 1: About you and your circumstances

Section 2: Your household

Section 3: Your income (earnings)

Section 4: Your income (savings, capital and other)

Section 5: Your income (benefits)

Section 6: Your partner's income (earnings)

Section 7: Your partner's income (benefits)

Section 8: Your partner's income (savings, capital and other)

Section 9: Expenditure

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