"*" indicates required fields Referrer's DetailsName* First Last Organisation Phone*Email* Enter Email Confirm Email Client's DetailsName First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Phone*Can a message be left on this number?* Yes No Mobile Phone*Can a message be left on this number?* Yes No Email Enter Email Confirm Email Client Date of birth DD slash MM slash YYYY Interpreting Service Required Yes No Customers Preferred Spoken LanguageAfrican – OtherArabicBengaliChineseEnglishFarsiFrenchGaelicGermanGujeratiHindiKurdishOtherPakistaniPashtunPolishPunjabiRomanianSign LanguageSomaliSpanishTurkishUrduVietnameseWelshSupportWhat type of support do your clients need?* Energy Advice Benefits Advice Water Debt Advice Other (include more details in the ‘additional details’ section below File UploadAttach eligibility documents including your/your client’s latest fuel statement here. Drop files here or Select files Max. file size: 10 MB. Additional informationIf 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.GDPRBy 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
