Smart Energy Action Plan Referral Form

Smart Energy Action Plan Referral Form
Please complete the form below for smart energy advice through our Smart Energy Action Plan service, for yourself or someone you support.

This service is open to anyone in England and Wales and who meets one of the following criteria:
- those in private or social rental housing.
- those in, or at risk of, fuel poverty.
- those with additional communication, access or safety needs (e.g. living with children under the age of 5, have health conditions or a disability, are of pensionable age, etc).
Are you submitting a referral for yourself?*

YesNo
Who are you referring? By submitting the form you are also confirming they have given permission to share their information.

A friend or relativeA client or patient
Your organisation (REFERRER)
Your name (REFERRER - ideally who the client spoke to)

First NameLast Name
Your email (REFERRER)
example@example.com
Is the customer on National Grid Electricity Distribution's Priority Services Register? If not, or if you are unsure, check eligibility and sign them up to the PSR on the details below before making this referral

Yes, the client is on the PSR
If needed, you can sign your client up to the Priority Services Register here https://www.nationalgrid.co.uk/customers-and-community/priority-services
Name*

TitleFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Email
example@example.com
Phone number*
Please describe the best you can in a paragraph or two the reason for the referral. (For example, support with smart meters, heat pumps or solar, smart tariffs, generic advice on smart and low-carbon technologies, etc.)*
Contact preferences (e.g. any days to avoid, AM/PM call preference)
Does the client have a smart meter? (Optional)

YesNoNot sure
Is the client confident using digital technologies? (Optional)

YesNoNot sure
Does the client have access to a smartphone or tablet (optional)

YesNoNot sure
Is the customer on National Grid Electricity Distribution's Priority Services Register?

YesNo
Date the client spoke with referrer

MonthDayYear
Date
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
Should be Empty: