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 and they will take your referral over the phone. Please enable JavaScript in your browser to complete this form.Your title *Your first name *Your surname *Your job title *Your workplace *Your department/team *Your email *Your phone number *How did you hear about Nottinghamshire Healthy Housing Service? Healthy Housing training sessionLeaflet At an event Newsletter Word of mouth Other If other, please let us know the details below.Client's title *Client's first name *Client's surname *Client's address (please include the postcode) *Client's date of birth (DD/MM/YYYY) *Client's email address Client's phone number *Please select the statements that relate to your client: *The house is coldThe heating is inefficient The heating is brokenThe house is damp They are in debt with their energy company They are disabledOther If other, please include more details below. Please select any benefits your client receives: *Child Tax CreditPension CreditIncome Related Employment & Support AllowanceIncome-based Job Seeker's AllowanceIncome SupportDisability Living AllowanceNoneUnsureOther If other, please include more details below. What service(s) do you think your client could benefit from? *Home Insulation (homeowners and private tenants only)Boiler and Heating Assistance (homeowners and private tenants only)Energy SwitchingPriority Services RegisterFuel Vouchers (County residents and pre-payment customers only)Severn Trent Water Bill ReductionUnsureOther If other, please include more details below. Does the client require a carer or a family member to be present for us to contact and ask for further information? *YesNoOther (please add more information below) Any additional information about the client? Submit