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First Name (required)
Family Name (required)
Your Date of Birth (required)
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Have you been to see us before?
If yes, when did you visit us?
The CAB service aims to provide equal opportunities and fair treatment for all people regardless of race, sex, disability, sexual identity or marital status.
In order to achieve these aims we have a policy of monitoring certain information relating to our clients. Please help us by completing the following questions.
All information on this form is confidential
Monitoring information will only be used for statistics
If you choose not to answer the following questions it will not affect your case
MaleFemaleDecline to Answer
Would you describe yourself as disabled?
YesNoDecline to Answer
How would you describe your ethnic group?
Please select from the following listWhite BritishWhite IrishWhite OtherMixed White & Black CaribbeanMixed White & Black AfricanMixed White & AsianMixed OtherAsian or Asian British IndianAsian or Asian British PakistaniAsian or Asian British BangladeshiAsian or Asian British OtherBlack or Black British CaribbeanBlack or Black British AfricanBlack or Black British OtherChineseOtherDecline to Answer
Your monthly income
Please select from the following listLess than £400£400-£599£600-£999£1000-£1499£1500-£1999£2000-£2499£2500-£2999More than £2999Decline to Answer
Type of Household
Please select from the following listCoupleCouple with dependant childrenSingle personSingle person with dependant childrenSingle person with non-dependant childrenOther adult onlyOther with dependant childrenDecline to Answer
Please select from the following listI own my home outrightI am buying my home (mortgage etc)My home has shared ownershipI rent from a social landlord (eg Local Authority)I rent from a private landlordI live in rent-free housingI live in a hostelI am a prisonerI am homeless (inc B&B tenant)OtherDecline to Answer
Please select from the following listSingleMarried/Co-Habiting/Civil PartnershipMarried but separatedDivorcedWidowedDecline to Answer
Please select from the following listEmployed and working at least 30 hours per weekEmployed and working less than 30 hours per weekUnemployedVolunteerRetiredStudentLooking after home or familyDecline to Answer
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