Home and Well NHS Staff Referral form
The Home and Well Remote Service is hosted and delivered by Citizens Advice Offices based across Hampshire, Portsmouth, Southampton and the Isle of Wight. Please provide some basic contact details (obtained with appropriate GDPR consent) so we may contact your patient as soon as possible. The Home and Well Remote Service will offer support with:

1. Help with signing up to the Priority Services Register for Electric and Gas supplies. This will mean that the patient receives a priority rapid response during any outage
2. We work with Water companies to help customers with their payment challenges via water tariffs.
3. An initial assessment of the patient's home circumstances regarding fuel poverty (having a warm home)
4. Conducting an initial assessment of the Patients social needs such as their financial position, housing needs and other support that surrounds them
5. Connecting patients to specialist partners within their local community to ensure they are provided with the "wrap around" support they need.

We would normally make contact within 3 working days from the date of referral; but as you will appreciate, this timescale may extend as a result of the current challenges we face due to the Coronavirus.
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Email *
Your name *
What is your role/relationship with the patient? *
Which NHS premises or location (town) are you referring from? *
Has the patient agreed to share their confidential information with Citizens Advice? By clicking yes you are agreeing on their behalf *
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