Warm and Safe Homes Advice – Self Referral Form There is currently a high demand for WASH 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.Your detailsYour name(Required) Forename Surname Your address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Your telephone numberYour email address (if you have one) Your date of birth DD slash MM slash YYYY Other informationWho supplies your gas and electricity?GASELECTRICITY Add RemoveDo you use a prepayment meter? YES NO How can we help you?(Required)Please give as much information so that we know which member of the team will best help you.Consent By ticking this box you confirm that: You are aware your personal details will be kept by NEA for the purpose of completing this referral. Any information you supply will be stored and processed according to NEA’s Privacy Notice. Consent Please tick this box to confirm your understanding of the above
