Privacy notice

Have you read the CityCLAC Privacy Notice?

I have read and accept the CityCLAC Privacy Notice

PIP Form Filling Service

About you

Are you completing this form for yourself or on behalf of someone else?

I am completing this form for myself

I am completing this form for someone else

Please provide your name and organisation

Are you currently a student or employee of City, University of London?

I am a current student at City, University of London

Are you happy for a student volunteer to provide referral information?

Due to conflicts of interest we cannot offer current staff and students advice appointments with a lawyer, but can provide referral information for other organisations or sources of help. These referrals will be provided by student volunteers working with CityCLAC.

I am a member of professional staff at City, University of London

Are you happy for a student volunteer to provide referral information?

Due to conflicts of interest we cannot offer current staff and students advice appointments with a lawyer, but can provide referral information for other organisations or sources of help. These referrals will be provided by student volunteers working with CityCLAC.

I am a member of academic staff at City, University of London

Are you happy for a student volunteer to provide referral information?

Due to conflicts of interest we cannot offer current staff and students advice appointments with a lawyer, but can provide referral information for other organisations or sources of help. These referrals will be provided by student volunteers working with CityCLAC.

None of the above

What is your current employment status?

To make sure our services are appropriately accessed by those most in need, please let us know about your financial situation below.

Unemployed

Employed full-time

What is your annual income?

Employed part-time

What is your annual income?

Retired

Student full-time

Student part-time

How did you hear about the City Community Legal Advice Centre (CityCLAC)?

Internet search

Website: City, University of London

Website: LawWorks

Word of mouth

Other

Where did you hear about CityCLAC?

Another Advice Agency

Which organisation specifically?

Community Centre

Which community centre?

About your PIP form

Are you receiving assistance to complete your PIP form from another agency?

Yes

What is the name of the agency and are they still helping you?

No

Have you received a copy of a Personal Independence Payment form? (These forms are around 30 pages long)

If you do not have a Personal Independence Payment form, you can obtain one by calling the Personal Independence Payment Enquiry Line on 0800 121 4433, Monday to Friday, from 8.00am to 5.00pm.

Yes

No

Have you received Personal Independence Payment before?

Yes

Do you have a copy of your previous claim form that you can bring to your appointment?

No

Do you need help because you are renewing an existing Personal Independence Payment award?

Yes

When does your existing award expire?

No

Are you currently receiving Personal Independence Payment and asking us to help you with an application to increase your existing award?

Yes

When does your existing award expire?

No

What type of PIP form do you need help with?

First time PIP form

Renewal form

Review form

Did you request the review of your PIP, or was it started by the DWP?

Mandatory reconsideration

Appeal

I don't know

What is the deadline for returning your PIP forms?

If you do not have a Personal Independence Payment form, you can obtain one by calling the Personal Independence Payment Enquiry Line on 0800 121 4433, Monday to Friday, from 8.00am to 5.00pm.

Please can you give us details of any illnesses or disabilities that you have?

What daily living needs and/or mobility restrictions do you experience?

Please tick all that apply.

Preparing foodEating or drinkingManaging therapy or monitoring a health conditionWashing and bathingManaging toilet needs or incontinenceDressing and undressingCommunicating verballyReading and understanding signs, symbols and wordsEngaging with other people face to faceMaking budgeting decisionsPlanning and following journeysWalking outdoors in a straight line

How far can you walk before stopping due to pain/discomfort/breathlessness?

Please can you give us details of any medication that you have been prescribed or buy over the counter, and which of your conditions this medication is used for?

Is there anything else we should know at this stage?

If offered an appointment, do you have any additional access or support requirements?

i.e. interpreter, wheelchair access, etc.

Our appointments can last up to 3-hours and take place in-person at the City Law School building, however we can sometimes accommodate telephone sessions.

Our address: City Community Legal Advice Centre (CityCLAC), City Law School Building, 165 Goswell Road, London EC1V 7HD

I am happy with an in-person appointment

I cannot attend in-person

Why are you not able to attend in-person?

Equality and diversity monitoring

Ethnicity

The descriptions are based on the government’s 2001 Census. This question is not about your nationality, place of birth or citizenship – it is about the group to which you as an individual perceive you belong.

Select an Option ASIAN - British-Indian ASIAN - British-Pakistani ASIAN - British- Bangladeshi ASIAN - Indian ASIAN - Pakistani ASIAN - Bangladeshi BLACK - British-Caribbean BLACK - Caribbean BLACK - British-African BLACK - African CHINESE - British-Chinese CHINESE - Chinese MIXED - White & Black Caribbean MIXED - White & Black African MIXED - White & Asian MIXED - Mixed Background WHITE - White-English WHITE - White-Welsh WHITE - White-British WHITE - White Non- European WHITE - White-Scottish WHITE - White-Irish WHITE - White- European Other Prefer not to say

Gender

Select an Option Male Female Intersex Non-binary Other Prefer not to say

Is the gender you identify with the same as your gender registered at birth?

Select an Option Yes No Prefer not to say

Do you consider that you have a condition or impairment that falls within the below definition of disabled?

The Equality Act 2010 defines disability as “a physical or mental impairment” which “has a substantial and long-term adverse effect on [a person’s] ability to carry out normal day-to-day activities”.

Select an Option Yes No Prefer not to say

Age

Select an Option Under 18 18-65 65+ Prefer not to say

Religion

Select an Option Buddhist Christian Hindu Jewish Muslim Sikh No religion Other Prefer not to say

Sexual orientation

Select an Option Heterosexual Bi-sexual Lesbian Gay Other Prefer not to say

Final declaration

Do you want to continue with your request for legal advice?

I confirm that I would like to proceed with my enquiry