General Self Referral Form

This form is now archived, please use this link to refer yourself, a client, or a patient to us. https://www.cse.org.uk/my-home/contact-us-for-energy-advice/

Which Local Authority do you live in?*
Which area do you live in?*
Berkshire Local Authorities*
Bristol Local Authority*
Hampshire Local Authorities*
Somerset Local Authorities*
Wiltshire Local Authorities*
Oxford Local Authorities*
West Sussex*
Surrey*
In your area we are only funded to give advice if you are eligible for the Priority Services Register with National Grid, your network operator. Please tick below if the following applies to you or someone in your household, and you would like to be signed up to the service:
- Pensionable age
- Disabled or chronically sick
- Have a long-term medical condition
- Have a hearing or visual impairment or additional communication needs
- Vulnerable situation such as mental health conditions
- Child under 5
- Already on the Priority Services Register
I agree to and confirm the above
Unfortunately you do not live in an area where we are funded for advice. Please visit our web page for further information www.cse.org.uk/advice/advice-and-support/support-from-energy-suppliers-during-covid-19
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Phone Number*
Email
example@example.com
Date of birth.

MonthDayYear
Date
Your Tenure*

HomeownerPrivately rentingHousing association tenantCouncil tenantBoaterTravellerOther
Do you need any advice for the following?

InsulationHeating (including renewable and low carbon technologies)
What other support may you need help with?

Water paymentsEnergy billsSwitching supplierBenefits advicePriority Services RegisterDebt adviceWarm Home DiscountOther
Please upload an income and expenditure form if possible as this is likely to speed up the process. If you do not have one please follow instructions below.

Browse Files

Cancelof
If you are unable to upload an income and expenditure form, please complete 'Your budget' on the National detbline site and email it to us at: Home.Energy@cse.org.uk

https://tools.nationaldebtline.org/yourbudget/

If you are unable to complete 'Your budget' our team will still assist you when we make contact, although it may take longer.
Briefly describe your situation and how you heard about us.*

0/2500
How did you hear about us?
Data protection

The information you provide on this form will be kept by the Centre for Sustainable Energy for the purposes of completing this referral, and will be stored and processed according to our privacy notice which can be found at www.cse.org.uk/privacy-policy.
Please tick this box to confirm your understanding of the above.
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