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PORTAL
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Positive Steps Form
First Name
*
Last Name
*
Address Line 1
Address Line 2
Post Town
County
Post Code
*
Borough
Thamesmead Resident
*
Thamesmead Resident
YES
NO
Peabody resident
*
Peabody resident
YES
NO
Email address
*
Contact Number
*
Date of Birth
*
Gender
Gender
Male
Female
Prefer not to say
Ethnicity
*
Ethnicity
White British
White Irish
White European
Greek-Cypriot
Turkish-Cypriot
Kurdish
Turkish
White Other
Mixed White & Black African
Mixed White & Black Caribbean
Mixed White & Asian
Indian
Pakistani
Bangladeshi
East African Asian
Asian Other
Black British
Black Caribbean
Black African
Black Other
Chinese
Other
Number of adults in household
Number of children (under 18) in household
Do you receive any of the following benefits?
Do you receive any of the following benefits?
Job Seekers Allowance
Universal Credit
Housing Benefit
Working Tax Credit
Income Support
Employment Support Allowance
Disability Living Allowance
Other
Not in receipt of any benefits
Landlord
Landlord
Private
Social
Who is the name of your landlord?
Do you consider yourself to have a disability?
Do you consider yourself to have a disability?
Yes
No
Prefer not to say
Do you currently have any money worries and in need of debt advice?
Do you currently have any money worries and in need of debt advice?
Yes
No
Are you at risk of? Or have
Are you at risk of? Or have:
Eviction or homelessness
Bailiff action
Court date/hearing
Utility disconnection
Would you like to attend a smart money workshop?
Would you like to attend a smart money workshop?
Yes
No
Are you looking for a low cost loan?
Are you looking for a low cost loan?
Yes
No
Do you need any advice about any of the following?
Do you need any advice about any of the following?
Rent
Bills
Benefits
Housing
Are you interested in saving?
Are you interested in saving?
Yes
No
Are you going to struggle to feed yourself/your family over the coming week?
Are you going to struggle to feed yourself/your family over the coming week?
Yes
No
Would you like some advice on how to find employment or volunteering?
Would you like some advice on how to find employment or volunteering?
Employment
Volunteering
Do you need advice regarding a disability?
Do you need advice regarding a disability?
Housing
Employment
Benefits
Other
Do you need information or advice about immigration?
Do you need information or advice about immigration?
Yes
No
Do you need support with your mental health?
Do you need support with your mental health?
Yes
No
Do you need support with getting physically active?
Do you need support with getting physically active?
Yes
No
Consent for storing submitted data
*
Yes, I give permission to store and process my data
No, I don't consent to storing and processing my data
