Havering Energy Doctors - Referral Form

Title

First Name

Surname

Telephone Number

Email

House/Flat Number

Street Name

Town

Post Code

Date of Birth (DD/MM/YYYY)

Gender

Ethnicity

Health Conditions (please state)

On average, how would you describe your home throughout the winter: Very Cold Cold Quite Cold Quite Warm Warm Very Warm

Do you have any problems with damp or mould? Yes No

Accommodation Status Owner Occupier Private Rented Council Tenant Sheltered Mobile Home

Do you have difficulties paying your energy bills? Yes No

If you are aged 50+ and would like a benefit check, please tick this box and our Advice and Information team at Age UK RBH will get in touch with you. Request Benefit Check

If you are under 50 and would like a benefit check, please get in touch with Citizen’s Advice Havering on 0808 189 8273

If you would like information on benefits, debt and other support available in Havering, please tick this box. Request Information on Benefits/Debt/Other Support

Who referred you for this service? I referred myself I was referred by an organisation (please state below)

Referring Organisation

Where did you hear about us? Word of mouth Leaflet Online Promotional Talk Other

I agree for my details to be passed on to Age UK East London to carry out the Home Energy Check Yes No