Referral Form

Referral Form
Referrers Details
Your Organisation*
Your Name*
Your Telephone
Your email*
A copy of this referral will be sent to you at this address, for your records
Date of Submission

DayMonthYear
Date
By completing the form below you confirm your client has granted you permission to enter their personal data, and for us to speak to them or leave a message. 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 NameLast 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 occupierPrivate rentedLocal AuthorityHousing AssociationLiving with Family/FriendsShared OwnershipOther (Please describe in Notes)
Referral requested for the following advice/support, (choose all that apply)

Energy/Heating AdviceFirst Time Central HeatingCavity wall insulationLoft insulationLED Light BulbsRadiator Reflector PanelsDraught ProofingSwitching TariffsWhite GoodsElectricity DebtGas DebtWater DebtAffordability/Fuel BillsBroken/Faulty heating system, (see note 1 below)Heating system upgrade, (see note 2 below)Damp/Mould
(1) The client’s primary source of heat (e.g. gas central heating boiler, storage heaters, gas/electric room heater) is not functioning, or regularly breaking down.

(2) The client’s primary source of heat is working, but old/inefficient, and a replacement is being sought.
Is the client in a no-heat situation?
Does the client have fixed auxiliary heaters, e.g.: gas fire or electric heaters that can provide heat while we assess options to support them in repairing/replacing their broken appliance?
Is the client without hot water?
The client’s primary source of hot water (e.g. gas central heating combi boiler, hot water cylinder) is not functioning, or regularly breaking down
Please let us know about any vulnerabilities

Health condition affected by coldLow incomeBenefitsOther vulnerabilities, please describe below
Optional Notes
What happens next?

Our advice team constantly monitors our central email inbox, so your referral will receive an initial assessment within the next few working days. Due to a massive increase in demand for our services, we are prioritising cases of extreme vulnerability, as we’re sure you’d expect.

Currently we are prioritising clients in the following situations:

•             Prepay customers at risk of self-disconnection, without the means to top up their meters without financial assistance

•             Vulnerable residents in a “no heat situation” (i.e. they have no access to a safe heating source, such as a working boiler, gas fire, electric heater etc.)

•             Vulnerable residents living in damp/mouldy properties

If your referral is for a resident with access to heat, without damp/mould issues, and without an immediate risk of being without gas or electricity, they will be contacted on a first-come, first-served basis. It may be several weeks before we are able to make contact. Please advise your client accordingly.

For an update on a referral you have submitted, please email us at advice@epplus.org and somebody will be able to advise you what the current status is of your referral. Please allow a few working days for responses to these enquiries.”
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