Warm and Safe Homes Referral

Referrer's Details

Name*

First Last

Organisation*

Phone*

Email*

Enter Email Confirm Email

Client's Details

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Support

What type of support do your clients need?*

Select All
Energy Advice
Benefits Advice
Water Debt Advice

File Upload

Attach eligibility documents including your/your client's latest fuel statement here.

Drop files here or

Additional information

If there is any other information you think we should be made aware of please include it here. Please include information about the issue, any progress or actions already taken, any known deadlines or any sensitive matters to be aware of.

GDPR

By ticking the box below you confirm that:

• The client has given their permission for you to pass their information on to NEA.

• You have explained the purpose of doing so and made the client aware that their information will be used by a member of the team to contact them.

• You are processing the client’s data lawfully.

• You are aware your personal details will be kept by NEA for the purposes of completing this referral.

• Any information you supply below will be stored and processed according to NEA's privacy notice

Please tick this box to confirm your understanding of the above.*

I agree to the information above

CAPTCHA