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Please complete a Healthy Housing referral form on behalf of your client.

If you are having any problems with the form please contact the team directly on 0115 985 3009 – they can take your referral over the phone and also rectify the glitch on the form.

FIRSTLY, PLEASE ENTER YOUR DETAILS

Title

First name

Surname

Job title

Workplace

Department/Team

Email

Telephone number

How did you learn about The Healthy Housing Service?
Healthy Housing Training sessionLeafletWeb searchAt an eventWord of mouthOther

PLEASE ENTER YOUR CLIENT'S DETAILS

Client's title

Client's first name

Client's surname

Client's address (please include postcode)

Date of birth

Client's email (if they have one)

Client's mobile (if they have one)

Client's landline (if they have one)

Please select the following statements that relate to your client:
The house is coldThe heating is inefficientThe heating is brokenThe house is dampThey're in debt with their energy companyThey are disabledOtherNone

Please select any benefits the client receives:
Child Tax CreditPension CreditChild Tax CreditIncome Related Employment & Support AllowanceIncome-based Job Seeker's AllowanceIncome SupportDisability Living AllowanceOtherNoneUnsure

What service(s) do you think they could benefit from?
Home InsulationBoiler AssistanceHome VisitEnergy SwitchingUnsure

Any comments?