Warm Homes, Healthy Futures Servicing (Only) Referral Form 1Referral Guidance2Referrer Details3Client Details Unique IDReferral GuidancePlease refer to the Guidance Notes for further information on referring people for energy advice and support as part of the Warm Homes, Healthy Futures programme.Does your client or patient have a health condition or disability that is made worse by living in a cold, damp, or poor quality home?(Required) Yes No Take a look at our Warm and Safe Homes advice pages for details of other assistance that may be available.By completing this form on behalf of another person, you are confirming that they consent to: ♦ You requesting support from National Energy Action. ♦ Being contacted by National Energy Action to progress their referral for energy advice and support. ♦ Having their name, address and contact details stored by National Energy Action.Do you have permission?(Required) Yes I have permission Referrer DetailsReferrer's name(Required) First Last Organisation(Required) Email(Required) Enter Email Confirm Email Client DetailsClient's name(Required) First Last Address(Required) Address Line 1 Town/City ZIP / Postal Code Please provide a contact number to reach the person on.(Required)Can a message be left on this number? Yes No Client email address (if they have one) Enter Email Confirm Email Does the client require translation/interpretation services?(Required) Yes No If yes, please select which languageSELECTAfrican – OtherArabicBengaliChineseEnglishFarsiFrenchGaelicGermanGujeratiHindiKurdishPakistaniPashtunPolishPunjabiRomanianSign LanguageSomaliTurkishUrduVietnameseWelshDoes your client belong to one of the following priority groups?(Required)SELECTCarerDisabledExpectant parentFamily with a disabled childFamily with a child under 5Long-term illnessOver 65 years oldUnemployedNon specifiedDoes the client’s health issues fall within any of the following categories (tick all that apply). Multiple Impairments Dementia Arthritis Cancer Asthma COPD Autism Learning disability Anxiety Depression Physical Disability Diabetes Heart Problems Kidney Disease (Kidney Dialysis) Terminal Diagnosis Other Consent(Required) The client has given their permission for you to pass their information on to NEA. 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 NEA for the purposes of completing this referral. Any information you supply will be stored and processed according to NEA’s Privacy Notice. Please tick this box to confirm your understanding of the above
