Please complete our Healthy Housing form so we can check if you qualify for any of our home improvement or well being services.

You will need to have a valid email address to complete the form.

Healthy_Housing_Logo

YOUR DETAILS

First name

Surname

Date of birth

Email

Telephone number

Address (please include your postcode)

PROPERTY INFORMATION

Tenure

If you are a private tenant or landlord please complete the following landlord details:

Landlord address

Landlord telephone number

Landlord email address

How many people live at the property?

How many years have you lived at the property?

What type of property is it?

What's the property detachment?

How many storeys does the property have?

Any additions to the property?
ConservatoryExtensionLean toPorchNo additions

What's the main wall type?

What's the existing wall insulation?

What's the roof type?

If the loft is insulated, where is the insulation located?

What's the loft insulation depth?

When was the property built?

YOUR HEATING

How do you heat your home?

If you have a boiler, how old is it?

What sort of boiler do you have?

What's the make of your boiler (if you know it)?

What's the boiler model (if you know it)?

Who is your gas supplier?

How do you pay for your energy?
Direct debitPay on receipt of billPre paymentOther

HEALTH, BENEFITS AND INCOME

Does anyone anyone in the property suffer from one or more of the following long-term illnesses? Please select.
StrokeHeart problemsRespiratory problemsMobility problemsDiabetesCancerOtherNone

Does anyone in the household receive any benefits? Please select.
Working Tax CreditChild Tax CreditHousing BenefitCouncil Tax BenefitIncome SupportInc. Related Sup. AllowanceDisability Living AllowancePension CreditAttendance AllowanceWar DisablementUniversal CreditDisability PremiumPiPNone

If you are a SINGLE householder are your personal saving less or more than £8,000?
less than £8,000more than £8,000Not applicable

If you are JOINT householders and you both live at this address, are your joint savings less or more than £12,000?
less than £12,000more than £12,000Not applicable

WHAT SERVICES ARE YOU INTERESTED IN?
Loft InsulationWall InsulationBoiler and Heating AssistanceEnergy SwitchingEnergy Advice