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Lamplight pre-appointment questionnaire

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Royal College of Nursing / Get Help / Member Support Services (MSS) / Lamplight Support Service /

Lamplight pre-appointment questionnaire

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

Date of appointment *

Full Name *

RCN membership number

Postcode *

Telephone number *

Email *

Section 2 - Your household

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

Just me

Partner

Children

Adult family member

Lodger

Other

Tick all that apply

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

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

What best describes your living situation? *

Homeowner (no mortgage)

Homeowner (with mortgage)

Rent from private landlord or agency

Rent from council or housing association

Living with relatives or friends and paying rent

Living with relatives or friends rent free

Shared ownership

Homeless

How many bedrooms do you have? *

Section 3 - Your income (benefits)

Do you currently receive any benefits? *

Yes (Please enter below)

No (Please skip to Section 4)

If you receive benefits, please tell us which ones below.

Child benefit

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

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 4 - Your income (Earnings)

Do you currently have any earnings from employment? *

Yes

No (Please skip to Section 5)

How many hours per week do you work?

How much are your earnings after deductions?

Please enter your net pay

Section 5 - 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 6 - Your partner

Do you have a partner living with you? *

Yes

No (Please skip to Section 10)

Section 7 - Your partner's income (benefits)

Does your partner currently receive any benefits?

Yes (Please enter below)

No (Please skip to section 8)

Child Benefit

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Council Tax Support

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Disability Living Allowance (DLA)

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Employment and Support Allowance

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Housing Benefit

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Jobseeker’s Allowance

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Personal Independence Payment (PIP)

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

State Pension

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Tax Credits

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Universal Credit

Please tell us the amount your partner gets paid for this benefit and how frequently they get paid this benefit. Leave blank if not received

Other benefit

If your partner gets any other benefits, please provide details, including how much and how often they get paid it.

Section 8 - Your partner's income (Earnings)

Does your partner receive any earnings from employment?

Yes

No (Please skip to Section 9)

How many hours per week does your partner work?

How much does your partner earn after deductions?

Please enter your partner's net pay

Section 9 - Your partner's income (Savings, capital and other)

Does your partner have any savings or capital? ? If so, please enter the approximate value(s)

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 10 - Essential costs. (Please enter costs that you / you and your partner are responsible for paying. Please enter all costs as monthly.)

Housing payments (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

Landline telephone and internet

Mobile phones

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

Road tax and insurance for your primary household vehicle

(Please exclude fuel costs)

Union subscriptions

Section 11 - Captcha

Please prove you are human

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