Referral Form

Referral Form
Referrers Details
Your Organisation
Your Name *
Your Telephone
Your email *
example@example.com
By completing the form below you confirm your client has granted you permission to enter their personal data. Information on this form will be held and used by Energy Projects Plus for the purposes of providing the assistance requested. This information will not be given to other agencies without your client’s prior approval. Any information provided will be held and used in accordance with the General Data Protection Regulation. Our Privacy Policy can be accessed here.
Client Details
Full name *

First Name Last Name
Address
Town & Locality
Post Code, (partial postcode will suffice if entire code is not known) *
Local Authority *
Telephone *
Alternative Telephone
Email
example@example.com
My home is

Owner occupier Private rented Local Authority Housing Association Living with Family/Friends
Referral requested for the following advice/support, (choose all that apply)

Energy/Heating Advice First Time Central Heating Boiler Repair / Replace Cavity wall insulation Loft insulation LED Light Bulbs * Radiator Reflector Panels * Draught Proofing * Switching Tariffs White Goods Electricity Debt Gas Debt Water Debt Affordability/Fuel Bills
* Installation of these measures is currently suspended and due to recommence in September. We will be happy to keep clients on a waiting list, so will still accept any referrals.
Please let us know about any vulnerabilities

Health condition affected by cold Low income Benefits Other vulnerabilities, please describe below
Optional Notes
Energy Projects Plus makes at least three attempts to contact each new client. Please note, we do not deliver an emergency service. For help completing this form, or if you have any other queries, call the Save Energy Advice Line free on 0800 043 0151. Lines are open 9am-5pm, Monday-Friday (apart from bank holidays)
File upload here if needed. Please display the name of the client in the file name, thank you.

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Referral Form

Referrers Details

Client Details