Referral for HEET Visit

Please use this form to refer yourself or another person for HEET's services. NB: HEET only accepts referrals for residents of the London boroughs of Enfield or Waltham Forest.

Please let us know whether you are applying for a HEET visit for yourself or you are making a referral on behalf of someone else.
I am applying for myself
I am making a referral for someone else

Householder details: Title:
First name: Surname*: Address 1*: Address 2: Address 3: Postcode*:
Primary contact number*: Secondary contact number: Email address: Third-party contact: Relation to client: Third-party contact number:

Further information: Reason for referral (please include information that you think is relevant e.g. age of householder, cause for concern, maximum 250 characters):

"I consent to my contact information being shared with HEET. I understand that a HEET staff member will telephone me to ask me further questions to confirm my eligibility for their services and to arrange a home visit. I understand that this may include questions regarding my health and financial status and/or that of members of my household.

"I understand that HEET will not use my personal information for marketing purposes or share my details with third parties without my explicit consent, except where the law allows for the sharing of information for the purposes of prevention and detection of crime or where I or another person would otherwise be at risk of serious harm."

Please tick below to confirm that you agree to the above statement.

Consent given*:

* Required fields.

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Referral for HEET Visit