HomeEnergy ConneCT Enrollment

1
Welcome!

We look forward to co-creating custom energy upgrade plans with you to save money and improve the comfort, health, and performance of your home.

The data we collect helps us prepare for our first 30-minute conversation and provide you with initial customized referrals to contractors and financial resources. Our work conforms to the Privacy Policies of our parent organization, NHS of New Haven, and you’re welcome to reach out to us with any questions at hello@homeenergyconnect.org.

We look forward to connecting with you!
2
Authorize us to help you!* This field is required.Sign here to confirm you agree to the NHS Privacy Statement
Clear
3
What is your first and last name?* This field is required.
First Name
Last Name
4
How did you hear about HomeEnergy ConneCT?* This field is required.
Please Select an Option
Please Select an Option
A Friend or Neighbor
Junta for Progressive Action
Community Action Agency of New Haven (CAANH)
REPS - DEEP - ICast
City of New Haven Canvassers
City of Hartford (city hall, social services, newsletter)
Sustainable Fairfield
HeatSmart
Community organization (NRZ, Hartford NEXT, senior center, community center)
Home Contractor
NHS of New Haven
System Smart/Michael Uhl
Sign (flier, poster, street banner, etc.)
Other
5
What are your goals for completing energy upgrades for your household? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
6
What is your primary language?
Please Select
Please Select
English
Spanish
Portuguese
French
Other
7
What is your phone number?* This field is required.
8
What is your email address?* This field is required.
example@example.com
9
Which way(s) do you prefer for us to communicate with you?Please select all that apply.
Email
Text
Phone
Home visit
10
Which gender most accurately describes you?* This field is required.
Please Select
Please Select
Woman
Man
Non-binary
Prefer not to say
Other
11
Are there pronouns or a nickname you would prefer our team to use when addressing you?
12
How many people live in your household?* This field is required.
13
Are you the head of your household?* This field is required.
YESNO
14
Is anyone in your household a Veteran?* This field is required.
YESNO
15
Is anyone in your household disabled?
YESNO
16
Are you Hispanic/Latino?* This field is required.
YESNO
17
Which racial identity most accurately describes you?* This field is required.
Chose not to respond
Please Select
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Chose not to respond
18
Are you on fixed income (retirement, social security pension, disability, etc)?* This field is required.
YESNO
19
What is your household income range?* This field is required.
Please Select
Please Select
$19,999 or less
$20,000 - $24,999
$25,000 - $29,999
$30,000 - $34,999
$35,000 - $39,999
$40,000 - $44,999
$45,000 - $49,999
$50,000 - $54,999
$55,000 - $59,999
$60,000 - $64,999
$65,000 - $69,999
$70,000 - $79,999
$80,000 - $98,999
$99,000 - $119,999
$120,000 - $150,000
$150,000 or more
20
What is your birth date?Your birth date helps to determine eligibility for age-dependent programs and is required on some forms.
Date
Month
Day
Year
21
What is the street address of the home we can help you upgrade?* This field is required.
Street Address
Apt, Unit, or Bldg
City
Please Select
Please Select
CT
AK
AL
AR
AZ
CA
CO
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Which of the following best describes your relationship with this home?* This field is required.
I own this home, and also live there.
I own this home, but do NOT live there.
I am a tenant in this home.
23
What type of home do you own?* This field is required.
Single family house
Two unit building
Three unit building
Four unit building
Five or more unit building
Other
24
What year did you purchase your home?
25
Are you planning to move in the next 2-3 years?
YESNO
26
Do you have Central Air?* This field is required.
YESNO
27
What type(s) of system(s) heats your home?* This field is required.
Hot Air (Ducted)
Hot Water (Radiators/Baseboards)
Steam (Cast Iron Radiators)
Ductless Minisplit
Electricity (Baseboards)
Space Heater (plug-in)
Fireplace
Wood or pellet stove
Other
28
What fuels your heating system(s)?* This field is required.
Electricity
Oil
Natural Gas
Propane
Wood
Pellets
Other
29
What fuels your hot water heater?* This field is required.
Electricity
Natural Gas
Propane
Oil
Biomass
Other
30
What fuels your cooking range and oven?* This field is required.
Electricity
Natural Gas
Propane
Biomass
Other
31
What fuels your clothes dryer?* This field is required.
Electricity
Natural Gas
Propane
Oil
Biomass
Not Applicable
Other
32
What fuels your household's vehicle(s)?
Gasoline
Electricity
Hybrid
Diesel
Not Applicable
Other
33
Roughly how many miles does your household drive each year?
34
Do you produce solar electricity at your home?
YESNO
35
What is your source for drinking water?* This field is required.
Municipal system
Well
Other
36
What is your wastewater system?* This field is required.
Sewer connection
Septic
Other
37
How many units are there in the building?* This field is required.
Single family house
Two unit building
Three unit building
Four unit building
Five or more unit building
Other
38
When is this home used?
Year-round
Seasonally
39
What year did you purchase this home?
40
Do this home have Central Air?* This field is required.
YESNO
41
What type(s) of system(s) heats the home?
Hot Air (Ducted)
Hot Water (Radiators/Baseboards)
Steam (Cast Iron Radiators)
Ductless Minisplit
Electricity (Baseboards)
Space Heater (plug-in)
Fireplace
Wood or Pellet Stove
Other
42
What fuels the heating system(s)?* This field is required.
Electricity
Oil
Natural Gas
Propane
Wood
Pellets
Other
43
What fuels the hot water heating?* This field is required.
Electricity
Natural Gas
Propane
Oil
Biomass
Other
44
What fuels the cooking range and oven?* This field is required.
Electricity
Natural Gas
Propane
Biomass
Other
45
What fuels the clothes dryer?* This field is required.
Electricity
Natural Gas
Propane
Oil
Biomass
Not Applicable
Other
46
Do you produce solar electricity at this home?
YESNO
47
What is the source for drinking water?* This field is required.
Municipal system
Well
Other
48
What is the wastewater system?* This field is required.
Sewer connection
Septic
Other
49
How many units are there in your building?* This field is required.
Single family house
Two unit building
Three unit building
Four unit building
Five or more unit building
Other
50
When is your home used?* This field is required.
Year-round
Seasonally
51
What year did you move into this home?
52
Are you planning to move in the next 2-3 years?
YESNO
53
Do you have Central Air?* This field is required.
YESNO
54
What type(s) of system(s) heats your home?
Hot Air (Ducted)
Hot Water (Radiators/Baseboards)
Steam (Cast Iron Radiators)
Ductless Minisplit
Electricity (Baseboards)
Space Heater (plug-in)
Other
55
What fuels your heating system(s)?
Electricity
Oil
Natural Gas
Propane
Wood
Pellets
Other
56
What fuels your hot water heating?* This field is required.
Electricity
Natural Gas
Oil
Propane
Biomass
Other
57
What fuels your cooking range and oven?* This field is required.
Electricity
Natural Gas
Propane
Biomass
Other
58
What fuels your clothes dryer?* This field is required.
Electricity
Natural Gas
Propane
Oil
Biomass
Not Applicable
Other
59
What fuels your household's vehicle(s)?
Gasoline
Electricity
Hybrid
Diesel
Not Applicable
Other
60
Roughly how many miles does your household drive each year?
61
Do you produce solar electricity at your home?
YESNO
62
What is your source for drinking water?* This field is required.
Municipal system
Well
Other
63
What is your wastewater system?* This field is required.
Sewer connection
Septic
Other
64
What is the name of the property owner?* This field is required.
First Name
Last Name
65
What is the phone number of the property owner?* This field is required.
66
What is the email address of the property owner?
example@example.com
67
When can we connect?* This field is required.This is a brief video or phone call meeting to ensure the right next steps are defined.
68
Get Page URL
69
Will you be willing to recommend us?
Yes
No
70
How easy was enrollment?
1
2
3
4
5
71
Are you planning to purchase a home in the next 2-3 years?
YESNO
72
What type of home do you rent?
Single family house
2-4 family house
5+ family building
Other
73
Are you a Landlord?
YESNO
74
Are you a Homeowner?* This field is required.
OwnerRenter
75
What is your age?
76
If "Other", how did you hear?Clarification to "How did you hear about the program?"
77
What is a second available date in the next two weeks when we can meet (in-person or virtually) at your home?
Date
Year
Month
Day
78
What is one available date in the next two weeks when we can meet (in-person or virtually) at your home?
Date
Year
Month
Day
79
Have you completed a Home Energy Solutions assessment in the last two years?
YESNO
80
When making decisions for your home, which is the SECOND MOST important?
Overall Cost
Environmental Benefit
Comfort or Functional Improvement
81
When making decisions for your home, which is MOST important?
Overall Cost
Environmental Benefit
Comfort or Functional Improvement
82
Which utilities do you currently use?Select all that apply
Electric
Oil
Natural Gas
City Water/City Sewer
Propane
Wood or other biomass
Solar PV
Other
83
Are you renting your home?
YESNO
84
What is the primary reason you want to participate?
85
When is your home used?
Year-round
Seasonally
Should be Empty: