WASH Referral

There is currently a high demand for WASH Advice services. We aim to respond to you within two weeks. Please complete the form below with all of the information that we have requested. It will help us more quickly deal with your enquiry.

Referrer's details

Name(Required)

Forename Surname

Job title

Organisation(Required)

Telephone number(Required)

Email address(Required)

Enter Email Confirm Email

Client's details

Client's name(Required)

Forename Surname

Client's address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Client's telephone number

Client's email address (if they have one)

Enter Email Confirm Email

Client's date of birth

Other information

Who supplies the client's gas and electricity(Required)

GAS

ELECTRICITY

Does the client use a prepayment meter?(Required)

YES

NO

Are you looking for a fuel top-up voucher for the client?(Required)

YES

NO

Can you please supply proof of benefits and proof of supplier (this can be a screen shot from an app)

Max. file size: 10 MB.

What type of support does your client need?(Required)

Energy Advice

Benefits Advice

Water Debt Advice

Attach eligibility documents including your client's latest fuel statement here.

Drop files here or

Max. file size: 10 MB.

Please include information about the issue, any progress or actions already taken, any known deadlines or any sensitive matters to be aware of.(Required)

WASH Advice Referral Form – CLIENT REFERRAL

There is currently a high demand for WASH Advice services. We aim to respond to you within two weeks. Please complete the form below with all of the information that we have requested. It will help us more quickly deal with your enquiry.

Referrer's details

Client's details

Other information

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