Cold to Cosy Homes referral

Please complete this form if you are applying for someone else.

Please enter any brief comments on eligibility and any requirements of each visit such as draught proof front door.

Applicant details:

Is there anyone (e.g. a carer or relative) who should be the primary contact used to arrange the visit?
If yes, please enter their details below:
  • Title
  • First name
  • Surname
  • Alternative contact number (home)
  • Alternative contact number (mobile)
  • Email
If they own their own home AND their gas central heating is broken, then please select Yes. Otherwise please select No.
How did the applicant hear about this scheme?

Please read the following to the client:

"I understand that a member of staff at Cumbria Action for Sustainability and the LEAP contact centre will telephone me to ask me further questions to confirm my eligibility for the scheme and arrange a home energy 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 my personal information will not be shared with or used by anyone outside this programme without my explicit consent unless 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 confirm that you read the consent statement out to the applicant and that they agreed to you sharing their information with us.