Benefits Advice Referral Form 1Referrer Details2Client Details3Other information There is currently a high demand for benefits advice services. We aim to respond to you within two weeks. Please complete the form below with all of the information that we have requested. It will help us more quickly deal with your enquiry.Referrer's detailsName(Required) Forename Surname Job title Organisation(Required) Telephone number(Required)Email address(Required) Enter Email Confirm Email Client's detailsClient's name(Required) Forename Surname Client's address(Required) Street Address Address Line 2 City ZIP / Postal Code Client's telephone numberClient's email address (if they have one) Enter Email Confirm Email Client's date of birth DD dash MM dash YYYY Other informationWho supplies the client's gas and electricity(Required)GASELECTRICITY Add RemoveDoes the client use a prepayment meter?(Required) YES NO Are you looking for a fuel top-up voucher for the client?(Required) YES NO Can you please supply proof of benefits and proof of supplier (this can be a screen shot from an app)Max. file size: 10 MB.What type of support does your client need?(Required) Energy Advice Benefits Advice Water Debt Advice Select AllAttach eligibility documents including your client's latest fuel statement here. Drop files here or Select files Max. file size: 10 MB. Please include information about the issue, any progress or actions already taken, any known deadlines or any sensitive matters to be aware of.(Required)Consent(Required) By ticking this box 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 will be stored and processed according to NEA’s Privacy Notice. Consent(Required) Please tick this box to confirm your understanding of the above
