Warm Home Prescription

Please provide as much information as possible. If you are unable to complete a field that isn’t a problem, but we may need to contact you if further information is required, to enable us to best support the individual. We’ll only do this when necessary. Thank you.

If you have any questions when completing this form please email warmhomeprescription@nea.org.uk

By completing this form on behalf of another person, you are confirming that they have given you permission to request support from National Energy Action. You are confirming that the person consents to being contacted by National Energy Action to progress their referral for energy advice and support. You are confirming that they have given consent for their name, address and contact details to be stored by National Energy Action.(Required)

Referrer's Details

Name(Required)
Email(Required)

Client/Individual Details

Name(Required)
Email
Address(Required)
Preferred contact method(Required)
Date of birth
Tick here if the individual is receiving end of life care
Is the patient in receipt of a SR1 form?
Benefits received (if known)
Client has fuel debt?
Tick here if the patient is dependent on the use of medical equipment in the home
e.g. You can tell us if the individual likes to be contacted on a specific day or time. Please also tell us if they have a lasting power of attorney for property and financial affairs. Or any other information you think would be helpful for us to be aware of.