Wales & West Utilities Energy Support Referral 1Referrer Details2Client Details3Other information There is currently a high demand for 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.Referrer's detailsName(Required) Forename Surname Job titleOrganisation(Required)Telephone number(Required)This field is hidden when viewing the formTelephone 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 numberClient's email address (if they have one) Enter Email Confirm Email Client's date of birth(Required) Day Month Year Other informationWho supplies the client's gas and electricity(Required)GASELECTRICITYWhat type of GAS meter does the client have?(Required) Smart prepayment Traditional prepayment Smart credit Traditional Credit What type of ELECTRICITY meter does the client have?(Required) Smart prepayment Traditional prepayment Smart credit Traditional Credit Are you looking for a fuel top-up voucher for the client?(Required) YES NO Confirmation of income(Required)Please confirm that you have received evidence that the client’s household income is less than £30,000. Confirmed Evidence of supplier (Prepayment meter)(Required)Please confirm that you have evidence that the client uses a prepayment meter add tick box Confirmed Evidence of supplier (Credit meter)Please attach the most recent supplier bill showing the full page with name, address, account number and balance.Max. file size: 10 MB.Can you please supply proof of benefits and proof of supplier (this can be a screen shot from an app) Drop files here or Select files Max. file size: 10 MB. What type of support does your client need?(Required) Energy 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)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. Consent(Required) Please tick this box to confirm your understanding of the above