Warm Home Prescription - National Energy Action (NEA)

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nea.org.uk

National Energy Action
Cymru
Northern Ireland

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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)

Yes I give permission

Unique ID

Name of team/trust/referral agency(Required)

Referrer's Details

Name(Required)

First Last

Position/Job title

Email(Required)

Enter Email Confirm Email

Phone(Required)

Client/Individual Details

Name(Required)

First Last

Home telephone number(Required)

Mobile telephone number(Required)

Email

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 Town/City County Post Code

Council area(Required)

Please state

Preferred contact method(Required)

Home telephone

Mobile telephone

Email

Preferred language

Date of birth

Income band (if known)

Tick here if the individual is receiving end of life care

Yes

Is the patient in receipt of a SR1 form?

Yes

No

Benefits received (if known)

Attendance Allowance

Carers Allowance

Child Benefit

Child Tax Credit

Council Tax Reduction

Covid 19 – Income Reduced

DLA/PIP

ESA (Support Group)

ESA (Work Related)

Housing Benefit

Income Support

JSA

JSA – income based

Low Income Benefits Unknown

Low Income No Benefits

Manager approved eligibility (Cadent)

Mortgage Support

Not Given

Other

Pension Credit (Guarantee)

Pension Credit (Savings)

Private Pension

Social Fund (Sure Start Maternity Grant, Funeral Payment, Cold Weather Payment)

State Pension

Support for Mortgage Interest (SMI)

Universal Credit

Universal Credit – LCWRA

Working Tax Credit

Household status (if known)

Housing status (if known)

Client has fuel debt?

Yes

No

If yes, what i the approximate amount?

Tick here if the patient is dependent on the use of medical equipment in the home

Yes

Electric meter type

Gas meter type

Notes

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.

Consent(Required)

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. Please tick this box to confirm your understanding of the above.

I confirm

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