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* 1. Are you renting the property?

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* 2. Is your property affected by black mould, heat loss or damp?

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* 3. What year did you move into the property roughly?

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* 4. Do you or anyone who lives with you suffer from the following?

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* 5. How many children in your property suffer from any of the above health conditions?

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* 6. If you are completing instructions on behalf of a child who has personal injuries please complete this question. If not please skip.

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* 7. What is the name and address of your GP Surgery?

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* 8. Contact Details

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* 9. To assess whether you qualify for Legal Aid please confirm if you are in receipt of any of the following

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* 10. Please ensure the National Insurance number and benefit selected is correct as we require it to apply for legal aid (i.e. free legal advice for you). If your benefits are paid into a partner's account please include their name and National Insurance number.

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* 11. If your landlord is definitely NIHE please skip. (this will be on your tenancy agreement) If your landlord is not NIHE but another housing association please enter their name. Examples include Apex Housing Association, Clanmil Housing Association, Choice Housing Association Ltd., Grove Housing Association Ltd., Newington Housing Association Ltd., North Belfast Housing Association Ltd., Radius Housing Association Ltd., Rural Housing Association Ltd.,

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* 12. Is there anything else that we can do to help you?

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