We want to make sure our services are shaped by your needs. We will also use the information to check that our services are fair and accessible to everyone. Your information is protected by law. Please see our privacy statement for further information.
Accurate contact details ensure we can send you important service information and appointment reminders. If there is a second person listed on your tenancy agreement, please give their details in the joint tenant section below.
Please tell us your address:
Title
Mrs
Ms
Miss
Mr
Mx
Dr
Other
Full name
Preferred name (if different to above)
Which pronouns should we use when we refer to you?
She/her
He/him
They/them
Ze/zir
Other
Prefer not to say
Email address
Mobile phone number
Landline phone number
Your health
You may qualify for our priority repairs service.
Do you have any physical or mental health conditions or illnesses lasting or expected to last 12 months or more?
Yes
No
Personal information
What is your main language?
English
Other
What is your ethnic group (please choose one section from A to E and tick one box to describe your ethnic background):
A White
English, Welsh, Scottish, Northern Irish or British
Irish
Gypsy or Irish Traveller
Roma
Other White background
B Mixed or multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Other mixed or multiple background
C Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other Asian background
D Black, Black British, Caribbean or African
Caribbean
African background
Other Black, Black British or Caribbean background
E Other ethnic group
Arab
Any other ethnic group
What is your religion?
No religion
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion
How do you describe your gender?
Woman
Man
Transwoman / Transman
Non-binary / Genderqueer
Agender / Gender fluid
Don't know
Prefer not to say
Other
Which of the following best describes your sexual orientation?
Straight / Heterosexual
Gay or Lesbian
Bisexual
Prefer not to say
Other
Is this a joint tenancy?
Yes
No
Please give details of who else lives in your home. Leave blank if this does not apply.
Add extra household memberIs there anything you would like us to know about you or your household that may have an impact on the service we provide? If yes, please write brief details here.
For example, please allow extra time for me to answer the door.
Thank you. Your questionnaire has been submitted.
