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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 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 session
Leaflet
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 cold
The heating is inefficient
The heating is broken
The house is damp
They are in debt with their energy company
They are disabled
Other

If other, please include more details below.

Please select any benefits your client receives: *

Child Tax Credit
Pension Credit
Income Related Employment & Support Allowance
Income-based Job Seeker's Allowance
Income Support
Disability Living Allowance
None
Unsure
Other

If other, please include more details below.

What service(s) do you think your client could benefit from? *

Home Insulation
Boiler and Heating Assistance
Home Visit
Energy Switching
Priority Services Register
Severn Trent Water Bill Reduction
Unsure
Other

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? *

Yes
No
Other (please add more information below)

Any additional information about the client?

Contact us

Call us on 0115 985 9057.

Visit us at Queens Walk Community Centre, Queens Walk, The Meadows, Nottingham, NG2 2DF. We are located on the top floor.

Message us via our online form.

Our office & phone lines are open from Monday to Friday, 9am – 5.30pm.

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