Back You are requesting help for yourself Referral – Warm Together Cymru (Self Referral) 1Client Details2Other 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.This field is hidden when viewing the formReferring agency(Required)This field is hidden when viewing the formReferrer's name(Required)This field is hidden when viewing the formReferrer's email(Required) Enter Email Confirm Email This field is hidden when viewing the formReferrer's phone number(Required)Client DetailsThis field is hidden when viewing the formTitleSELECTMissMrMrsMsMxNoneForename(Required)Surname(Required)Date of Birth(Required) Day Month Year This field is hidden when viewing the formNationality(Required)SELECTAfghanAlbanianAlgerianAmericanAmerican SamoanAndorranAngolanAnguillanAntiguanArgentineArmenianArubanAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBosnianBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCaymanianCentral AfricanChadianChannel IslanderChileanChineseChristmas IslandChuukeseCocos IslanderColombianComoranCongoleseCook IslanderCosta RicanCroatianCubanCypriotCzechDanishDjiboutianDominicanDutchDutch AntilleanEcuadorianEgyptianEmiratiEquatorial GuineanEritreanEstonianEthiopianFalkland IslandFaroeseFijianFinnishFrenchFrench PolynesianFutunanGaboneseGambianGeorgianGermanGhanaianGibraltarGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHerzegovinianHonduranHungarianIcelandicI-KiribatiIndianIndonesianIranianIraqiIrishIsraeliItalianIvoirianJamaicanJapaneseJordanianKazakhstaniKenyanKittitianKoreanKosovanKosraenKuwaitiKyrgyzstaniLaotianLatvianLebaneseLiberianLibyanLiechtensteinLithuanianLuxembourgMacedonianMahoranMalagasyMalawianMalaysianMaldivianMalianMalteseManxMarshalleseMauritanianMauritianMexicanMicronesianMoldovanMonacanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMotswanaMozambicanNamibianNauruanNepaleseNevisianNew CaledonianNew ZealandNicaraguanNigerianNigerienNiueanNi-VanuatuNoneNorfolk IslanderNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPhilippinePitcairn IslanderPohnpeian(s)PolishPortuguesePuerto RicanQatariRomanianRussianRwandanSahrawiSaint HelenianSaint LucianSaint VincentianSalvadoranSammarineseSamoanSao TomeanSaudiSenegaleseSerbianSeychelloisSierra LeoneanSingaporeSlovakSlovenianSolomon IslanderSomaliSouth AfricanSpanishSri LankanSudaneseSurinameseSwaziSwedishSwissSyrianTaiwanTajikistaniTanzanianThaiTimoreseTobagonianTogoleseTokelauanTonganTrinidadianTunisianTurkishTurkmenistaniTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseVirgin IslanderWallisianYapeseYemeniZambianZimbabweanEthnicity(Required)SELECTAsian or Asian British BangladeshiAsian or Asian British IndianAsian or Asian British Other BackgroundAsian or Asian British PakistaniBlack or Black British AfricanBlack or Black British CaribbeanBlack or Black British Other BackgroundChineseEastern EuropeanMixed Other BackgroundMixed White & AsianMixed White & Black AfricanMixed White & Black CaribbeanOtherPrefer not to sayRomany, Gypsy, TravellerTBCWhite BritishWhite IrishWhite OtherClient's phone number(Required)Can leave message on home phone?(Required) Yes No Client's mobile phone number(Required)Can leave message on mobile?(Required) Yes No Client's email address Enter Email Confirm Email Preferred contact method(Required) E-Mail Home Telephone Mobile Telephone Address 1(Required)Address 2Address 3Town(Required)Postcode(Required) Other informationThis field is hidden when viewing the formBorough(Required)SELECTAncoats & ClaytonArdwickAshby WardAxholme Central WardAxholme North WardAxholme South WardBaguleyBallymaguiganBarking and DagenhamBarnetBarton WardBassetlawBellaghyBeswickBexleyBorder AreaBottesford WardBradfordBrentBrickhillBrigg and Wolds WardBromhamBromleyBrooklandsBroughton and Appleby wardBroxtoweBrumby WardBurnageBurringham and Gunness WardBurton upon Stather and Winterton WardCamdenCastleCastledawsonCauldwellCharlestownCheethamChorltonChorlton ParkCity CentreCity of LondonClaphamCrosby and Park WardCroydonCrumpsallDe ParysDidsbury EastDidsbury WestDraperstownEalingEnfieldFallowfieldFerry WardFroddingham WardGedlingGlebeGoldingtonGorton NorthGorton SouthGreenwichGulladuffHackneyHaltonHammersmith and FulhamHaringeyHarpurHarpurheyHarrowHaveringHigher BlackleyHillingdonHounslowHulmeIslingtonKempston EastKempston NorthKempston SouthKensington and ChelseaKingsbrookKingstonKingsway with Lincoln Gardens WardKnockloughrimLambethLecumpherLevenshulmeLewishamLongsightLower GlenshaneMagheraMansfield & AshfieldMerseysideMertonMid Beds DistrictMiles Platting & Newton HeathMoss SideMostonNewark & SherwoodNewhamNorthendenNot ApplicableNot KnownOakleyOld MoatOpenshawOther wardOuter LondonOutside AreaOutside MCCPutnoeQueens ParkRedbridgeRichmondRidge WardRushcliffeRusholmeSharstonSouthwarkSt HelensStroudSuttonSwatraghTobermoreTower HamletsTown WardTownspark EastTownspark WestUnidentifiedUpperlandsValleyWaltham ForestWandsworthWarringtonWestminsterWeston Super MareWhalley RangeWithingtonWoodhouse ParkWoottonThis field is hidden when viewing the formHousehold status(Required)SELECTCouple (no dependant children)Couple (with dependant children)Multigenerational (three or more generations)OtherSingle (with dependant children)Single AdultsThis field is hidden when viewing the formHousing status(Required)SELECTAssured or Secure TenancyAssured Shorthold TenancyHomelessHostelIntroductory TenancyLiving with Family – Paying RentLodger – Paying RentNomadic/Non-settledOtherOwns Home (Mortgage)Owns Home (outright)PrisonPrivate TenantRent FreeRenting – LARenting – PRSRenting – RSLRough SleeperShared OwnershipSocial TenantSofa SurferTolerated TresspasserThis field is hidden when viewing the formEconomic status(Required)SELECTCarerDecline To AnswerGovernment Work or Training SchemeIn Training or EducationOtherRefugeeRegistered UnemployedRetiredSelf EmployedStay at Home ParentStudentUnfit for WorkWorking Full Time (over 30 hours)Working Part TimeWorking Part Time (16 – 29 hours a week)Working Part Time (less than 16 hours a week)Preferred language(Required)SELECTAfrican – OtherAlbanianArabicBengaliChineseEnglishFarsiFrenchGaelicGermanGujeratiHindiHungarianKurdishKutchiMandarinMirpuriOtherPakistaniPashtunPolishPortugesePunjabiRomanianRussianSign LanguageSlovakSomaliSpanishSylhettiTigrinyaTurkishUkranianUrduVietnameseWelshInterpreting service required(Required) Yes No This field is hidden when viewing the formHas disability(Required) Yes No This field is hidden when viewing the formHealth issuesStart typing to find health issue. Please select all that applyAnxietyArthritisAsthmaAutismCancerCOPDDementiaDepressionDiabetesHeart problemsKidney disease (dialysis)Learning disabilityMultiple impairmentsPhysical disabilityTerminal diagnosisOtherUpload supporting document Drop files here or Select files Max. file size: 10 MB. This field is hidden when viewing the formPriority group(Required)SELECTCarerDisabledExpectant ParentFamilies with a disabled childFamilies with child under 5Long Term IllnessNon SpecifiedOver 65yrsUnemployedThis field is hidden when viewing the formBenefits(Required)Start typing to find benefit. Select all that applyAttendance AllowanceCarers AllowanceChild BenefitChild Tax CreditCouncil Tax ReductionCovid 19 – Income ReducedDLA/PIPESA (Support Group)ESA (Work Related)Housing BenefitIncome SupportJSAJSA – income basedLow Income Benefits UnknownLow Income No BenefitsManager approved eligibility (Cadent)Mortgage SupportNot GivenOtherPension Credit (Guarantee)Pension Credit (Savings)Private PensionSocial Fund (Sure Start Maternity Grant, Funeral Payment, Cold Weather Payment)State PensionSupport for Mortgage Interest (SMI)SurgeryTelephone AdviceUniversal CreditUniversal Credit – LCWRAWorking Tax CreditThis field is hidden when viewing the formElectricity Distribution Network Operator (DNO)(Required)SELECTElectricity North WestESP Utilities GroupGTC (Independent)Independent Power Networks LtdLast Mile Asset ManagementNational GridNorthern Ireland ElectricityNPG (Northern Powergrid)SPEN (Scottish Power Energy Networks)SSEN (Scottish and Southern Energy Networks)UKPN (UK Power Networks)This field is hidden when viewing the formFuel poor?(Required)SELECTAt RiskFuel PoorNot Fuel PoorThis field is hidden when viewing the formGas Distribution Network (GDN)(Required)SELECTCadentCadent – East AngliaCadent – East MidlandsCadent – EasternCadent – North LondonCadent – out of areaNGNPhoenix Energy NISGNWWU (Wales and West Utilities)This field is hidden when viewing the formFuel debt(Required) Yes No This field is hidden when viewing the formFuel debt amountSELECT£0 – £100£1001 – £1500£101 – £500£1501 +£501 – £1000Client in creditN/AElectric meter type(Required)SELECTElectric – Smart – CreditElectric – Smart – PPMElectric – Traditional – CreditElectric – Traditional – PPMElectricity supplier(Required)Gas meter type(Required)SELECTGas – Smart – CreditGas – Smart – PPMGas – Traditional – CreditGas – Traditional – PPMNo Gas SupplyGas supplier(Required)Please tick which support you are requesting Voucher Winter Wamth Support Pack NotesConsent(Required) By ticking this box I 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
