Name of Referring Person (required)

Referring Organisation (required)

Date of Referral (required)

Referrer's Email Address (required)

Referrer's Contact Number (required)

How long have you known the client, and in what capacity? (required)

Client Background (required) (Please provide a brief summary of the client's background and needs)

Type of Property (required)

Number of Rooms (required)
1234567891011121314151617181920
Is the property owned or rented? (required)
OwnedRented
Number of Residents (Adults aged 18-55) (required)
—Please choose an option—0123456789101112131415
Number of Residents (Adults aged 55+) (required)
—Please choose an option—0123456789101112131415
Number of Residents (Children under 18) (required)
—Please choose an option—0123456789101112131415
Family or individual? (required)
FamilyIndividual
Details of Vulnerabilities (required)

First Name (required)

Last Name (required)

Date of Birth (required)

Ethnicity (required) (Ethnic group categories taken from GOV.UK)
English, Welsh, Scottish Northern Irish or BritishIrishGypsy or Irish TravellerAny other White backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black, African or Caribbean backgroundArabWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed or multiple ethnic backgroundAny other ethnic group
Address (required)

Postcode (required)

Client's Email Address (required)

Client's Landline Number (required)

Client's Mobile Number (required)

Client's Preferred Method(s) of Contact (required) (Email, Mobile, Landline)

Does the client have a prepayment meter? (required)
Yes (please complete application)No (please refer to LBN Energy Advice Scheme)
Who is your gas supplier? (required)

Who is your electricity supplier? (required)

GDPR Consent - By clicking 'yes' here on this form you are consenting for your details to be passed on to Lancashire BME Network and voucher scheme providers to provide you with your vouchers and so that they are able to contact you and keep you informed of other services. (required)
Yes

Photo ID (required) (Passport, Driving License)

Address ID Number 1 (required) (Utility Bills, Council Tax, Bank or Benefit Statement/Letter)

Address ID Number 2 (required) (Utility Bills, Council Tax, Bank or Benefit Statement/Letter)

Prepayment Meter (required) (Photo of Prepayment Meter(s))

If you are unable to provide any of the above, please provide reasons as to why and submit the application. Each claim is handled on a case by case basis.
Reasons why information couldn't be provided OR any other notes.

Do you currently have any financial and/or fuel debt? (required) (If yes, provide details)

Do you currently claim any income-related benefits? (required)(If yes, list benefits)

Are you currently struggling to pay your fuel bills? (required) (If yes, provide brief detail of why)