New Referral Form 2020

Please tick this box to confirm your understanding of the above.*

I agree to the information above
Your details
Name

SalutationFirst NameLast Name
Full name*
Organisation*
Job title
Email
example@example.com
Telephone number*
If you would like us to update you on your client/patient please tick this box

I would like to be updated
Client's details
Name*

SalutationFirst NameLast Name
Full name*
Address*

First line

Second Line

TownCounty

Postcode
Full Address*
Local Authority
Area*
If you are unable to click this drop down please use the up and down arrows on your keyboard to select the area.
Berkshire Local Authorities*
Bristol Local Authority*
Hampshire Local Authorities*
Somerset Local Authorities*
Wiltshire Local Authorities*
Oxford Local Authorities*
West Sussex*
Surrey*
Bath and North East Somerset support householders under the Energy at Home scheme, this is no longer a service we provide. For support and referrals please visit https://www.energyathome.org.uk/
For casework support in this area your client or patient will need to be eligible and willing to be signed up to the Priority Services Register if they are not already on it. (Extra help for a power cut or water interruption).*

Yes
Client's tenure*

HomeownerPrivately rentingCouncil tenantHousing association tenantGypsy, TravellerBoaterNot known/NA
We are unable to accept referrals for council tenants in Bristol at this time. We apologise for the inconvenience.
Boat Name
Index Number
Mooring location
Any nearby landmarks etc.
Boat identifying features
Fuel boat company preference
Client's email
example@example.com
Client's phone number*
Would the client like us to contact someone else on their behalf?

Yes
Name*

First NameLast Name
Phone number*
Email
example@example.com
Client's date of birth

DayMonthYear
Date
Does the client need an interpreter?

YesNo
What language is required*
Does your client or patient have any access needs? (Large print, deaf, etc).
Is your client in hospital or have they recently been discharged?*

DischargedIn HospitalNot discharged or in hospital
Which hospital?*

Great Western HospitalSalisbury District HospitalOther
Other:
Discharge date if available

MonthDayYear
Date
What's the reason for your referral? Please give as much detail as possible, if there is insufficient information we may need to get in contact with you causing a delay.*

0/2500
Does your client have a working heating system?

YesNoNot known/NA
Does your client or patient have a terminal illness?

YesNoNot known/NA
Are you aware of any circumstances relating to the client that might be relevant to a risk assessment? If so please describe

YesNoNot known/NA
Please describe risk factor*

0/2500
If you are referring your client for energy debt, do they have other debts too?*

YesNoUnsure (please get this information if possible)
We are unable to provide this level of support with financial debt, we recommend also referring to Citizens Advice: https://www.citizensadvicesouthsomerset.org.uk/ You can still refer to us if this was not the only reason for the referral.
We are unable to provide this level of support with financial debt, we recommend also referring to Citizens Advice: https://www.citizensadvice.org.uk/ You can still refer to us if this was not the only reason for the referral.
Do you think your client needs extra help in a power cut or water interruption? (These services are also known as the Priority Services Register)

YesNoNot known/NA
Would you like to attach any relevant documents? Income and expenditure forms, medical notes, documents related to the issue etc. These help us with casework.

Yes (select to expand)No
Does your client have a long term physical or mental health condition made worse by living in a cold home?*

YesNo
If Yes, please describe condition below:

0/2500
Attachment 1

Browse Files

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Attachment 2

Browse Files

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Attachment 3

Browse Files

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Your client or patient will be referred to the Tenants Energy Advice team for support. Please be aware there will be a waiting list for first contact and casework.
By ticking the box below you confirm that:
- The client has given their permission for you to pass their information on to the Centre for Sustainable Energy.
- 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 the Centre for Sustainable Energy for the purposes of completing this referral.
- Any information you supply below will be stored and processed according to CSE’s Home Energy Team privacy notice, which can be found at https://www.cse.org.uk/privacy-policy/
Please tick this box to confirm your understanding of the above.*

I agree to the information above
Should be Empty:

Your details

Client's details