Home & Well Referral form
The Home & 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 client* as soon as possible. The Home & 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 client 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 client's home circumstances regarding fuel poverty (having a warm home)
4. Conducting an initial assessment of the client's social needs such as their financial position, housing needs and other support that surrounds them
5. Connecting client 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.

*client also refers to patient 
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Email *
Your name *
What is your role/relationship with the client? *
Which NHS premises or location (town) are you referring from? *
Has the client agreed to share their confidential information with Citizens Advice? 
The client has been informed how we hold their data and the purposes we use their data for: the provision of advice, to gather data to improve our service, and to support our research in a way they cannot be identified. Show the client our privacy policy if required.
 *
Does the client consent to Citizens Advice storing details of disability and health conditions? *
Required
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