Energy Advice and Support Service – CLIENT REFERRAL (Kayo) 1Referrer Details2Client Details3Other information4 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.Consent(Required) By ticking this box 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 will be stored and processed according to NEA’s Privacy Notice. Referrer's detailsName(Required) Forename Surname Job titleOrganisation(Required)Telephone number(Required)Email address(Required) Enter Email Confirm Email Client's detailsClient's name(Required) Forename Surname Client's address(Required) Street Address Address Line 2 City ZIP / Postal Code Client's telephone number(Required)Are we able to leave a message on this number?(Required) Yes No Client's email address (if they have one) Enter Email Confirm Email Client's date of birth DD dash MM dash YYYY Client's ethnicitySELECTAsian 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 CaribbeanRomany, Gypsy, TravellerWhite BritishWhite IrishWhite OtherOtherPrefer not to sayDoes the client require translation/interpretation services?(Required) Yes No If yes, please select which languageSELECTAfrican – OtherArabicBengaliChineseEnglishFarsiFrenchGaelicGermanGujeratiHindiKurdishPakistaniPashtunPolishPunjabiRomanianSign LanguageSomaliTurkishUrduVietnameseWelsh Other informationWho supplies the client's electricity?(Required)What type of electricity meter do they have?SELECTElectric – Smart – CreditElectric – Smart – PPMElectric – Traditional – CreditElectric – Traditional – PPMWho supplies the client's gas?(Required)What type of gas meter do they have?SELECTGas – Smart – CreditGas – Smart – PPMGas – Traditional – CreditGas – Traditional – PPMNo Gas SupplyAre you looking for a fuel top-up voucher for the client?(Required) YES NO Can you please supply proof of benefits and proof of supplier (this can be a screen shot from an app)Max. file size: 10 MB. What type of support does your client need?(Required) Energy Advice Benefits Advice Water Debt Advice Select AllAttach eligibility documents including your client's latest fuel statement here. Drop files here or Select files Max. file size: 10 MB. Please include information about the issue, any progress or actions already taken, any known deadlines or any sensitive matters to be aware of.(Required)
