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CYMRU
Northern Ireland
Leicester Referrals (New)
1
Referrer Details
2
Client Details
3
Other information
By completing this form on behalf of another person, you are confirming that they have given you permission to request support from National Energy Action. You are confirming that the person consents to being contacted by National Energy Action to progress their referral for energy advice and fuel voucher support. You are confirming that they have given consent for their name, address and contact details to be stored by National Energy Action.
Permission
(Required)
Yes, I give permission
Referrer's details
Please select your team
(Required)
SELECT
Leicester City Council
STAR
Wesley Hall
Other
Please give the name of your team
Name
(Required)
Forename
Surname
Job title
(Required)
Organisation
(Required)
Telephone
(Required)
This field is hidden when viewing the form
Telephone number
(Required)
Email address
(Required)
Enter Email
Confirm Email
Keep in touch
Please tick here if you would like to be contacted directly by the Leicester Energy Action (LEA), Leicester City Council and National Energy Action fuel poverty & health partnership to:
• Take part in the external evaluation for Leicester Energy Action by De Montford University
• Receive occasional once or twice a year feedback surveys from LEA, to inform continuous improvements to our referral processes and client experience.
• Provide good news/updates about the types of targeted advice and support our partnership offers, as well as grants and trust funds open nationally that may be useful for the clients you are assisting
I would like to subscribe to mailings from the partnership
Client's details
Client's name
(Required)
Forename
Surname
Client's address
(Required)
Street Address
Address Line 2
City
Postcode
Telephone
(Required)
Can a message be left on this number?
(Required)
Yes
No
Mobile Number
(Required)
Can a message be left on this number?
(Required)
Yes
No
Client's email address (if they have one)
Enter Email
Confirm Email
Client's date of birth
Day
Month
Year
What is the client's ethnicity?
(Required)
Select Ethnicity
Asian or Asian British Bangladeshi
Asian or Asian British Indian
Asian or Asian British Other Background
Asian or Asian British Pakistani
Black or Black British African
Black or Black British Caribbean
Black or Black British Other Background
Chinese
Eastern European
Mixed Other Background
Mixed White & Asian
Mixed White & Black African
Mixed White & Black Caribbean
Romany, Gypsy, Traveller
White British
White Irish
White Other
Other
Prefer not to say
Does the client require translation services?
(Required)
Yes
No
Please select which language
(Required)
Select Language
African – Other
Arabic
Bengali
Chinese
English
Farsi
French
Gaelic
German
Gujerati
Hindi
Kurdish
Pakistani
Pashtun
Polish
Punjabi
Romanian
Sign Language
Somali
Turkish
Urdu
Vietnamese
Welsh
Other information
Who supplies the client's gas and electricity
Type
NOT KNOWN
if you’re not able to identify the supplier(s).
GAS
ELECTRICITY
Account numbers
Type
NOT KNOWN
if you’re not able to identify the account numbers
GAS ACCOUNT NUMBER
ELECTRICITY ACCOUNT NUMBER
What type of gas meter does the client have?
Please select
Gas smart meter – credit
Gas smart meter – prepayment
Gas traditional – credit
Gas traditional – prepayment
No gas supply
What type of electricity meter does the client have?
Please select
Electricity smart meter – credit
Electricity smart meter – prepayment
Electricity traditional – credit
Electricity traditional – prepayment
Does the client identify under one of the following priority groups?
Please select
Carer
Disabled
Expectant parent
Family with a disabled child
Family with a child under 5
Long-term illness
Over 65 years old
Unemployed
None specified
Please specify
Attach eligibility documents including your client's latest fuel statement here.
Drop files here or
Select files
Max. file size: 2 MB.
Please include any information about the issue, any progress or actions already taken. Any known deadlines or sensitive issues to be aware of. Please advise what other forms of support the client has been referred into
(Required)
Consent
(Required)
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
.
Please tick this box to confirm your understanding of the above
