Referral form

Self Referral Form

Please fill out the form below. We will use this information to sort out, and process your claim.
Our advocate will work his magic, and use your information to sort out your claim with the DWP. Once completed click on "Submit".
We hope to reply to you in reference to the form within 3 working days. If you do not hear from us after that , please ring us on 07583 513 056

Please remember we are not a free service. Benefit Resolutions charges £100 per case, INSTALMENT PLANS ARE
OFFERED and we request 15% of ARREARS owed. There are no signed contracts. It is down to honesty and trust. This allows us to maintain our 96% success rate. All money made goes back into the business. We are a Community Interest Company, which means we do not make a profit BY LAW. All our charges are clearly laid out on our fees page.

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Name *

First

Last

Address *

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City

State

Zip Code

Country

Telephone *

Email *

Date Of Birth *

National Insurance Number *

Telephone Number *

Reason For Contacting Us *

Health Questionnaire

Name of General Practioner *

First

Last

Doctor's Surgery *

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City

State

Zip Code

Country

Health Professionals You Have Seen *

Health Conditions / Dates of Diagnosis *

Medication and Dosage *

How You Prepare Food *

Issues with Eating and Drinking *

How You Manage Your Treatments *

Washing *

Toilet Requirements *

Dressing *

Communicating *

Reading *

Mixing with Others *

Decisions About Money *

Going Out *

Moving Around *

Additional Information *

Submit