www.bhbh.org.uk
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URL:
https://www.bhbh.org.uk/make-a-referral/
Submission: On January 11 via manual from GB — Scanned from GB
Submission: On January 11 via manual from GB — Scanned from GB
Form analysis 1 forms found in the DOM
Name: BHBH Referral Form — POST
<form class="elementor-form" method="post" name="BHBH Referral Form">
<input type="hidden" name="post_id" value="39">
<input type="hidden" name="form_id" value="1e5fce6">
<input type="hidden" name="referer_title" value="Make a Referral - Better Housing Better Health">
<input type="hidden" name="queried_id" value="39">
<div class="elementor-form-fields-wrapper elementor-labels-above">
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bcb8c2b elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_bcb8c2b]" id="form-field-field_bcb8c2b" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="First Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ba23750 elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_ba23750]" id="form-field-field_ba23750" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Last Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7191906 elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_7191906]" id="form-field-field_7191906" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Company Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_962221c elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_962221c]" id="form-field-field_962221c" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Job Title" required="required" aria-required="true">
</div>
<div class="elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_b52dcdc elementor-col-50 elementor-field-required">
<input size="1" type="email" name="form_fields[field_b52dcdc]" id="form-field-field_b52dcdc" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Email" required="required" aria-required="true">
</div>
<div class="elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_f9b6b25 elementor-col-50 elementor-field-required">
<input size="1" type="tel" name="form_fields[field_f9b6b25]" id="form-field-field_f9b6b25" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Phone number" required="required" aria-required="true"
pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters (#, -, *, etc) are accepted.">
</div>
<div class="elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_83aac60 elementor-col-50 elementor-field-required">
<input size="1" type="tel" name="form_fields[field_83aac60]" id="form-field-field_83aac60" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Mobile Phone" required="required" aria-required="true"
pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters (#, -, *, etc) are accepted.">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_64a079c elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_64a079c]" id="form-field-field_64a079c" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="County" required="required" aria-required="true">
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8c84ef8 elementor-col-100"> If you are a referral partner who has completed the referral partner section of this form, we also need details
of the resident you wish to refer. Please confirm your company name below and then continue with the rest of the form. </div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0118d2f elementor-col-100">
<input size="1" type="text" name="form_fields[field_0118d2f]" id="form-field-field_0118d2f" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Company Name">
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_950f745 elementor-col-100"> If you are completing this form as a self-referral, please complete as much of the form below as possible about
your current circumstances. </div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b0b2412 elementor-col-50">
<input size="1" type="text" name="form_fields[field_b0b2412]" id="form-field-field_b0b2412" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Title">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1907823 elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_1907823]" id="form-field-field_1907823" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="First Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a17fb8b elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_a17fb8b]" id="form-field-field_a17fb8b" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Last Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_ad08caa elementor-col-50">
<input size="1" type="tel" name="form_fields[field_ad08caa]" id="form-field-field_ad08caa" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Mobile Phone" pattern="[0-9()#&+*-=.]+"
title="Only numbers and phone characters (#, -, *, etc) are accepted.">
</div>
<div class="elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_38b7f86 elementor-col-50 elementor-field-required">
<input size="1" type="email" name="form_fields[field_38b7f86]" id="form-field-field_38b7f86" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Email" required="required" aria-required="true">
</div>
<div class="elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_a33ed54 elementor-col-50 elementor-field-required">
<input size="1" type="tel" name="form_fields[field_a33ed54]" id="form-field-field_a33ed54" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Phone number" required="required" aria-required="true"
pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters (#, -, *, etc) are accepted.">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b4ad4f5 elementor-col-50">
<input size="1" type="text" name="form_fields[field_b4ad4f5]" id="form-field-field_b4ad4f5" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Address 1">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_499a389 elementor-col-50">
<input size="1" type="text" name="form_fields[field_499a389]" id="form-field-field_499a389" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Address 2">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cac76de elementor-col-50">
<input size="1" type="text" name="form_fields[field_cac76de]" id="form-field-field_cac76de" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="City">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e759e5f elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_e759e5f]" id="form-field-field_e759e5f" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="County" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_34939f1 elementor-col-50 elementor-field-required">
<input size="1" type="text" name="form_fields[field_34939f1]" id="form-field-field_34939f1" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Postcode" required="required" aria-required="true">
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a45190c elementor-col-100">
<label for="form-field-field_a45190c" class="elementor-field-label"> Please provide a brief description of your enquiry </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_a45190c]" id="form-field-field_a45190c" rows="4"></textarea>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_64b20ed elementor-col-100">
<label for="form-field-field_64b20ed" class="elementor-field-label"> Please select housing type </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_64b20ed]" id="form-field-field_64b20ed" class="elementor-field-textual elementor-size-sm">
<option value="Owner occupied">Owner occupied</option>
<option value="Private rental">Private rental</option>
<option value="Social renting">Social renting</option>
</select>
</div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_06b4c9a elementor-col-100">
<label for="form-field-field_06b4c9a" class="elementor-field-label"> Are there any safeguarding concerns we should be aware of? (Please provide a brief description) </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_06b4c9a]" id="form-field-field_06b4c9a" rows="4"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_518ac44 elementor-col-100">
<label for="form-field-field_518ac44" class="elementor-field-label"> Are there any communication/accessibility issues we should be aware of? (hard of hearing, ESL etc.) (please provide brief description) </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_518ac44]" id="form-field-field_518ac44" rows="4"></textarea>
</div>
<div class="elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_128dd48 elementor-col-100">
<label for="form-field-field_128dd48" class="elementor-field-label"> Type of enquiry </label>
<div class="elementor-field-subgroup "><span class="elementor-field-option"><input type="checkbox" value="High energy bills" id="form-field-field_128dd48-0" name="form_fields[field_128dd48][]"> <label for="form-field-field_128dd48-0">High
energy bills</label></span><span class="elementor-field-option"><input type="checkbox" value="Energy debt" id="form-field-field_128dd48-1" name="form_fields[field_128dd48][]"> <label for="form-field-field_128dd48-1">Energy
debt</label></span><span class="elementor-field-option"><input type="checkbox" value="Draughts, damp, condensation" id="form-field-field_128dd48-2" name="form_fields[field_128dd48][]"> <label for="form-field-field_128dd48-2">Draughts,
damp, condensation</label></span><span class="elementor-field-option"><input type="checkbox" value="Heating problems" id="form-field-field_128dd48-3" name="form_fields[field_128dd48][]"> <label for="form-field-field_128dd48-3">Heating
problems</label></span><span class="elementor-field-option"><input type="checkbox" value="Insulation" id="form-field-field_128dd48-4" name="form_fields[field_128dd48][]"> <label
for="form-field-field_128dd48-4">Insulation</label></span><span class="elementor-field-option"><input type="checkbox" value="Cold home" id="form-field-field_128dd48-5" name="form_fields[field_128dd48][]"> <label
for="form-field-field_128dd48-5">Cold home</label></span><span class="elementor-field-option"><input type="checkbox" value="Funding enquiry" id="form-field-field_128dd48-6" name="form_fields[field_128dd48][]"> <label
for="form-field-field_128dd48-6">Funding enquiry</label></span></div>
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4dc54f1 elementor-col-50">
<input size="1" type="text" name="form_fields[field_4dc54f1]" id="form-field-field_4dc54f1" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Advocate First Name">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e581cf5 elementor-col-50">
<input size="1" type="text" name="form_fields[field_e581cf5]" id="form-field-field_e581cf5" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Advocate Last Name">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f99655f elementor-col-50">
<input size="1" type="text" name="form_fields[field_f99655f]" id="form-field-field_f99655f" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Advocate Relationship">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7067f89 elementor-col-50">
<input size="1" type="text" name="form_fields[field_7067f89]" id="form-field-field_7067f89" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Advocate Telephone">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7d0a02c elementor-col-50">
<input size="1" type="text" name="form_fields[field_7d0a02c]" id="form-field-field_7d0a02c" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Advocate Email">
</div>
<div class="elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons">
<button type="submit" class="elementor-button elementor-size-sm">
<span>
<span class=" elementor-button-icon">
</span>
<span class="elementor-button-text">Submit</span>
</span>
</button>
</div>
</div>
</form>Text Content
Skip to content * Home * Make a Referral * About * Resources * Contact Menu * Home * Make a Referral * About * Resources * Contact Donate Menu MAKE A REFERRAL: If you’re comfortable, please use the online form below. If not, feel free to call us on this number 0800 107 0044 BHBH REFERRAL FORM: BHBH can only accept referrals from areas that we cover which include Buckinghamshire, Oxfordshire, Bedfordshire, Northamptonshire, Leicestershire, Norfolk, Cambridgeshire, Essex and Hertfordshire. If you do not live in any of these areas, we recommend you contact your local authority to see if they can offer additional support. If you are a referral partner who has completed the referral partner section of this form, we also need details of the resident you wish to refer. Please confirm your company name below and then continue with the rest of the form. If you are completing this form as a self-referral, please complete as much of the form below as possible about your current circumstances. Please provide a brief description of your enquiry Please select housing type Owner occupied Private rental Social renting Are there any safeguarding concerns we should be aware of? (Please provide a brief description) Are there any communication/accessibility issues we should be aware of? (hard of hearing, ESL etc.) (please provide brief description) Type of enquiry High energy bills Energy debt Draughts, damp, condensation Heating problems Insulation Cold home Funding enquiry Submit Are you, or do you know a resident who would like some advice on lowering energy bills, switching provider/tariff or accessing financial assistance? Fill out the form on this page with your contact details and a brief description of your query and one of our trained advisors will contact you within 3 working days (excluding weekends and bank holidays). You can also refer someone else, whether you’re a professional caseworker or a relation, friend or advocate. Or if you would like to chat to us about any aspect of keeping warm and well at home then contact our free helpline today on 0800 107 0044 (Monday to Friday 9:00-17:00, excluding bank holidays) or email us at bhbh@nef.org.uk. We will protect and process your personal information in accordance with our data protection policy, your personal information will only be used for the purposes of the projects that we are promoting through this Service; it will be kept by us on a secure database. We will seek your consent if we refer you on to any other service. Looking for Support? Contact BHBH BHBH IS HERE FOR YOU, CALL US TODAY ON: 0800 107 0044 Pages * Home * Make a Referral * About * Resources * Contact * Home * Make a Referral * About * Resources * Contact * Home * Make a Referral * About * Resources * Contact * Home * Make a Referral * About * Resources * Contact Resources * 10 Quick Wins to Save Energy * Making ECO flex work for you * Switching Energy Provider * Understanding your EPC * Understanding your gas and electricity bill * 10 Quick Wins to Save Energy * Making ECO flex work for you * Switching Energy Provider * Understanding your EPC * Understanding your gas and electricity bill Contact 0800 107 0044 bhbh@nef.org.uk Sign up to our Newsletter Sign Up Policies * Privacy Policy * Data Protection Policy * Safeguarding Policy * Privacy Policy * Data Protection Policy * Safeguarding Policy Sign up to our Newsletter Sign Up FS 646561 * 0800 107 0044 * Privacy Policy * Data Protection Policy * © National Energy Foundation 2022 * 0800 107 0044 * Privacy Policy * Data Protection Policy * © National Energy Foundation 2022 Facebook Twitter FS 646561 We are using cookies to give you the best experience on our website. You can find out more about which cookies we are using or switch them off in settings. Accept Reject Settings Close GDPR Cookie Settings * Privacy Overview * Strictly Necessary Cookies * 3rd Party Cookies Privacy Overview This website uses cookies so that we can provide you with the best user experience possible. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful. Strictly Necessary Cookies Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. Enable or Disable Cookies If you disable this cookie, we will not be able to save your preferences. This means that every time you visit this website you will need to enable or disable cookies again. 3rd Party Cookies This website uses Google Analytics to collect anonymous information such as the number of visitors to the site, and the most popular pages. Keeping this cookie enabled helps us to improve our website. Enable or Disable Cookies Please enable Strictly Necessary Cookies first so that we can save your preferences! Enable All Save Changes