Client application

Your Details

Surname*

Forename(s)*

Title

Address line 1*

Address line 2

Address line 4 (Town)

Postcode*

Local Authority*

Telephone no.*

Alternative phone no.

Email address

About your property

Tenure

Building Type

Property Type

Property Age

Number of Bedrooms

Wall Type

Loft Insulation Depth

Heating System Type

Fuel Type

Age of Heating System

Heating System status

Funding eligibility questions

DOB of oldest resident

Number of adults (over 18)

Number under 18s

Number under 5s

Does anyone at the property have any health conditions?

If yes, what is the main health condition

Other Health conditions (not listed)

Does anyone at the property receive any of the following benefits?

Total Household Income (before tax)

Mortgage/Rent and Council tax

Household Savings

Additional information

Do you have any problems paying your energy bills?

Yes

Are you in receipt of the Warm Homes Discount?

Yes

Do you have a smart meter?

Yes

Would you be interested in a free home safety check from the fire service?

Yes

Please let us know how we can help*

Please let us know how you heard about us

I am happy for my data to be stored securely on the Warm and Well database, and for Warm and Well to use it to contact me to provide advice and check my eligibility for funding. *