RCN Lamplight Support Service: Pre-appointment questionnaire

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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.

For details of how to book an appointment see here

Section 1 - About you and your circumstances

Date of appointment *

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

Full name *

RCN Membership Number

Email *

Telephone 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? (Select one) *

Who else lives in your household? (Tick all that apply) *

Just me

Partner

Children

Adult family member

Lodger

Other

Tick all that apply

How many bedrooms do you have? *

Is anyone in your household unwell or disabled? If so, please give details *

If you have any dependent children living with you, please state their ages and genders

Section 3 - Your income (Earnings)

Do you currently have any earnings from employment? (Select one) *

How many hours per week do you work?

How much are your earnings after deductions?

Please enter your 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? *

(E.g. maintenance for children, or an occupational pension)

Section 5 - Your income (benefits)

Do you currently receive any benefits? (Select one) *

Child benefit

Please enter the amount you get paid, and how often you get paid it. (E.g. £12.70 per week.)

Child maintenance

Please enter the amount you get and how often

Council Tax Support

Please enter the amount you get paid, and how often you get paid it.

Disability Living Allowance (DLA)

Please enter the amount you get paid, and how often you get paid it.

Employment and Support Allowance

Please enter the amount you get paid, and how often you get paid it.

Housing Benefit

Please enter the amount you get paid, and how often you get paid it.

Jobseeker’s Allowance

Please enter the amount you get paid, and how often you get paid it.

Personal Independence Payment (PIP)

Please enter the amount you get paid, and how often you get paid it.

State Pension

Please enter the amount you get paid, and how often you get paid it.

Tax Credits

Please enter the amount you get paid, and how often you get paid it.

Universal Credit

Please enter the amount you get paid, and how often you get paid it.

Other benefit

If you get any other benefits, please provide details, including how much and how often you get paid it.

Section 6 - Your partner and their benefits

Do you have a partner living with you? *

Child Benefit