Referral Form

Your Organisation

Your Name *

Your Telephone

Your email *

example@example.com

Date of Submission

Date

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.

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)

(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 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