energy efficient solutions, independent advice, insulation

Referral form (for organisations)

 

Referral for insulation, heating, LED replacement lighting and some other CEA services. For self-referrals please fill in the appointment form.

 

Please note: At present Community Energy Action works for customers in mid and north Canterbury (all Canterbury north of the Rangitata River) and in parts of the West Coast.

 

* indicates required field

Name and Contact Details
Patient / Client Name *
Installation address *
Suburb / RD No. *
City / Town *
Postcode find your postcode *
Phone (home) *
Phone (work)
Phone (mobile)
Email
Ownership details *
Does the person living in the house have a Community Services Card ? *
Services required
Health
There is someone in this household whose health would benefit from having their home's insulation and heating upgraded *
Full name of patient (if different from above)
Patient date of birth
NHI #
If referrer is not a medical professional or approved referrer, the patient must consent (please tick if verbal consent has been given)
Referrer Details
Referrer name *
Referrer type *
Organisation name *
Street address *
Suburb / RD No. *
City / Town *
Postcode find your postcode *
Referrer phone *
Referrer email *
Contact / Support Person (only if required)
Name (support person)
Relationship to patient / client
Phone (day)
Other
Comments:

Community Energy Action cannot guarantee that any insulation or heating measures can be installed until after the house has been assessed. Acceptance into the project is entirely at the discretion of Community Energy Action.

 

 

 

Community Energy Action

0800 GET WARM (0800 438 9276)

+64 3 374 7222

info@cea.co.nz

299 Tuam Street

Christchurch

 

 

© Copyright 2017 Community Energy Action Charitable Trust

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