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Healthy Housing front-line staff referral

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.

Your Details

Title

First Name(required)

Surname

Job Title(required)

Workplace(required)

Department/Team(required)

Email Address(required)

Telephone Number

Website

How did you hear about the Healthy Housing Service?(required)

Client's Details

Client's Title(required)

Client's First Name(required)

Client's Surname(required)

Clients Address (please include postcode)(required)

Client's Date of Birth (DD/MM/YYYY)(required)

Client's Email (if they have one)

Client's Mobile (if they have one)

Client's Landline (if they have one)

Please select the statements that relate to your client: The house is cold

The heating is inefficient

The heating is broken

The house is damp

They're in debt with their energy company

They are disabled

Please select any benefits the client receives: Child Tax Credit

Pension Credit

Income Related Employment & Support Allowance

Income-based Job Seeker's Allowance

Income Support

Disability Living Allowance

Other

None

Unsure

What service(s) do you think they could benefit from? Home Insulation

Boiler and Heating Assistance

Home Visit

Energy Switching

Prority Services Register

Severn Trent Water bill reduction

Unsure

Does the client require a carer or a family member to be present for us to contact and ask for further information?(required) Yes

No

Other

please add information in the comments space below.

Any additional comments about the client?

Thank you for making a referral on behalf of your client.

A member of the Nottinghamshire Healthy Housing Team will contact your client within two working days.

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Call us on 0115 985 9057.

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