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CLIENT DETAILS

Client Name

First Last

Client Email

Client Phone

Client Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Eligibility

Please select which option/s apply to your Client. You can select more than one.

Applying for

*Appliances/white goods referrals will only be considered if referred by a professional and Practitioner Referral Form is completed. Please email [email protected] to request a practitioner form if required.

Energy Advice Home Visit
*Appliances/White Goods
Gas Boilers Repair/Replacement
Cavity Wall / Loft Insulation
Renewable Energy Technologies including Solar & Heat Pumps
High Heat Retention Storage Heater Upgrade
Other Assistance, please detail below

Please use this to provide further information or queries.

Best appointment time

Our appointments are Monday to Friday. A convenient time will be discussed with your client, but this gives us an idea as to what times to offer to them.

AM
PM

How would your Client prefer to be contacted?

Please email
Please call

Assistance & Accessibility

Please detail any special assistance required

REFERRER DETAILS

Referrer name*

Referrer phone number*

Referrer email*

Referrer organisation*

How did you hear about Ridgewater Energy?*

This helps us to understand where we can reach people that require our support the most.

Consent*

I understand only residents that live in Dorset are eligible to apply through Ridgewater Energy

Consent*

I agree to the Privacy Policy

Consent*

Has the client provided express permission for you to refer them on their behalf?

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Energy Advice

Heating Advice

Renewable Energy

Insulation Resources

Professional Resources

Condensation & Damp Advice

Landlord Resources

Partner Referral Form

Refer YOUR CLIENTS NOW

This form is for frontline workers to refer their clients for support.

CLIENT DETAILS

REFERRER DETAILS