Housing Improvements and Repairs Form If you would like to make a referral for a person whose home needs improvement or repair please complete the below form and press 'submit' when finished. Name Address Telephone Number Check Vulnerability Is the patient over 60? Yes No Is the patient on income related benefit? Yes No Affordable warmth needs Is home cold and/or difficult to keep warm? Yes No Is the home damp? Yes No Can householder afford heating bills? Yes No Additional Information Housing health and safety hazards Is there concern by patient/occupier/family/medical practitioner that the house is in disrepair or hazardous in some way?For example: Is there a dangerous staircase? Yes No Is the house vulnerable to entry from intruders? Yes No Are there working smoke alarms? Yes No Do the electrics appear old and dangerous? Yes No Additional Information: Exacerbating Health Problems: Cardio Vascular? Yes No Respiratory? Yes No Mobility Problems? Yes No Additional Information Does patient give permission for a referral to be made to Housing Services/ Care and repair? Yes No Has the patient been given the telephone number of the B&NES Home Energy Team - 0800 082 2234? Yes No Contact Information For urgent safety improvements or repairs please contact WE Care and Repair on 01749 345 379 For further information, contact B&NES Housing Services (Standards and Improvements) on 01225 396444 To report comments or problems with the referral process contact Chris Mordaunt Housing Services Manager on 01225 396282 feed me To prevent automated spam submissions leave this field empty. Privacy notices
