Referral Form

• Referral for: Insulation and heating subsidies and free energy advice for low income households
  
  To be completed by a medical professional/social worker. If you are not a medical professional or social worker please fill in the appointment form.

• Eligibility criteria:

• • Patient / Client MUST have a valid (income-tested) Community Services Card, other conditions apply.
  • House built before the year 2000 (for insulation and heating subsidies).
  • Housing NZ or City Council tenants are NOT eligible for insulation and heating subsidies. However we can help these tenants in other ways e.g. free home energy advice. You could also contact Housing NZ or the City Council directly if you have any concerns about heating and insulation.

• Patient / Client Details
• Name:
• Age:
• Address
• Suburb/RD:
• City/Town:
• Postcode - Find your post code
• Phone (Home):
• Phone (Work):
• Mobile
• Patient Email
• Valid (income-tested)
  Community Services Card?
  Yes

  No

  Don't Know
• Is there someone in the household
  with a medical condition that
  is affected by a cold house?
  Yes

  No

  Don't Know
• Is the patient /client a:
  Homeowner

  Tenant in private rental

  Housing NZ or CCC tenant

  Don't Know

• Contact / Support Person (only if required)

• Name (Support Person):
• Relationship:
• Phone (Day):

• Referrer Details
• Name (Medical Professional):
• Type:
  Medical Centre

  Hospital Department

  Other
• Name of MC/Hospital Department/Other
• Address and Town / City
• Phone:
• Email Address

• 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.