warming communities

1Referrer Details

2Client Details

3Other Information

There is currently a high demand for our Energy Advice and Support Service. 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 Details

Referring agency(Required)

Referrer's name(Required)

Referrer's email(Required)

Enter Email Confirm Email

Referrer's phone number(Required)

Client Details

Title

Forename(Required)

Surname(Required)

Date of Birth(Required)

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Nationality(Required)

Ethnicity(Required)

Client's phone number(Required)

Can leave message on home phone?(Required)

Yes

Client's mobile phone number(Required)

Can leave message on mobile?(Required)

Yes

Client's email address

Enter Email Confirm Email

Preferred contact method(Required)

E-Mail

Home Telephone

Mobile Telephone

Address 1(Required)

Address 2

Address 3

Town(Required)

Postcode(Required)

Other information

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Borough(Required)

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Household status(Required)

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Housing status(Required)

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Economic status(Required)

Preferred language(Required)

Interpreting service required(Required)

Yes

Has disability(Required)

Yes

Health issues

Start typing to find health issue. Please select all that apply

Upload supporting document

Drop files here or

Max. file size: 2 MB.

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Priority group(Required)

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Benefits(Required)

Start typing to find benefit. Select all that apply

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Electricity Distribution Network Operator (DNO)(Required)

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Fuel poor?(Required)

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Gas Distribution Network (GDN)(Required)

Fuel debt(Required)

Yes

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Fuel debt amount

Electric meter type(Required)

Electricity supplier(Required)

Gas meter type(Required)

Gas supplier(Required)

Notes

Attendance Allowance
Carers Allowance
Child Benefit
Child Tax Credit
Council Tax Reduction
Covid 19 – Income Reduced
DLA/PIP
ESA (Support Group)
ESA (Work Related)
Housing Benefit
Income Support
JSA
JSA – income based
Low Income Benefits Unknown
Low Income No Benefits
Manager approved eligibility (Cadent)
Mortgage Support
Not Given
Other
Pension Credit (Guarantee)
Pension Credit (Savings)
Private Pension
Social Fund (Sure Start Maternity Grant, Funeral Payment, Cold Weather Payment)
State Pension
Support for Mortgage Interest (SMI)
Surgery
Telephone Advice
Universal Credit
Universal Credit – LCWRA
Working Tax Credit

Referral Form: Warming Communities

There is currently a high demand for our Energy Advice and Support Service. 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 Details

Client Details

Other information