RCN Lamplight Support Service: Pre-appointment questionnaire

Please complete the form after you've booked an appointment with the Lamplight team. All the information you provide is treated confidentially.

During your appointment, the adviser will explore other expenditure not asked about on this form. Please consider your monthly spending ahead of your appointment.

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? Have you received a grant from the RCN Foundation COVID-19 Support Fund in 2020? Yes No

If you answered yes, please note that you cannot apply for funding through Lamplight for three months after the payment date of your grant from the RCN Foundation COVID-19 Support Fund.

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)

How much available capital or savings do you have? Please include funds that you have across all open bank accounts.

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 monthly 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.

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

Please include:

A brief description of the issue you're having
Screenshots of any error messages, if possible
The device you're using (e.g. PC, laptop, mobile, etc.)
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Lamplight pre-appointment questionnaire