Please complete this form so we can understand your client's circumstances a little more. We can then determine which project or service is best suited to their needs.
1. Your Details
Title
Name
*
First Name
Last Name
Job Title
*
Workplace
*
Department/team
*
Telephone Number
Email
*
How did you hear about NEP/Healthy Housing Service
Healthy Housing training session
Online search / website
Local council
Magazine
Newsletter
Event
Leaflet
Social Media
Friend/Colleague
Radio
TV
Meadows Advice Group
The Bridges Community Trust
I've made a referral before
Back
Next
2. Client Details
Client's title
*
Client's name
*
First Name
Last Name
House Number/Name
*
Street/Road
*
Area
*
Postcode
*
Who's the client's local authority?
Please Select
Ashfield
Bassetlaw
Broxtowe
Gedling
Mansfield
Newark and Sherwood
Nottingham
Rushcliffe
Derby
Amber Valley
Leicestershire
Client's Date of Birth
-
Month
-
Day
Year
Client's Email
example@example.com
Client's preferred phone number
Please select the statement(s) that relate to your client.
The house is cold
The heating is inefficient
The heating is broken
The house is damp
They are in debt with their energy company
They are disabled
Other
Please select any benefits that your client receives
Attendance Allowance
Carers Allowance
Child Tax Credit (less than £16,800K)
Child Tax Credit (more than £16,800K)
Council Tax Benefit
Council Tax Support
Contribution based ESA
Housing Benefit
Disability Living Allowance
Disability Element/ Premium
Income Based JSA
Industrial Injuries Disablement
Income-Related ESA
Income Support
Pension Credit – Guarantee
Pension Credit – Savings
Personal Independence Payment (PIP)
Universal Credit
War Disablement Pension
Working Tax Credit (less than £16,800K)
Working Tax Credit (more than £16,800K)
Work Related Activity/Support
No benefits
What services do you think your client could benefit from?
Loft Insulation
Wall Insulation
Renewable Energy
Boiler / Heating Help
Health & Wellbeing Help i.e. Fuel Vouchers and Home Adaptations
Help with Debt, Benefits and/or their Water Bill
Does the client require a carer or a family member to be present when we contact them?
Yes
No
Please include any further information about the client you feel would be useful for us to know.
I agree to NEP keeping the client's details on its database, and sharing necessary data with 3rd partner agencies involved with providing relevant support and grant funding.
I consent
Submit
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