Referrals

THAW ORKNEY

Referral organisation: *

Contact Phone

Contact Email

Home Tel:

Total heating & electricity fuel costs:

Mobile Tel:

Referral date *

Date of birth

Preferred method of contact (if known)

Home Tel

Mobile Tel

THAW Orkney

Anchor Buildings, Bridge Street, Kirkwall,

KW15 1HR

United Kingdom

01856 878388

[email protected]

Level of urgency for contact (please select one option) *

As soon as possible

Potential risk to wellbeing

Immediate risk to wellbeing

Monthly Household Income, minus housing/childcare:

Estimated percentage of living/bedrooms heated to an adequate level:

Client Consent - Please tick *

This client gives their permission for me to pass on their information to THAW Orkney and understands that THAW Orkney will hold this information and treat it in the strictest confidence

Client name/s: *

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Enquiry Details - Summary of Enquiry: *

Making a Referral to THAW

Postcode:

If you are from an organisation/agency who wishes to make a referral to us, then please complete and submit the form below. Alternatively you can download a copy of our referral form found and email or post a completed form to us.

If you are an individual looking to refer yourself, then please complete a separate form found on our contact page. If we have asked for a letter of authority to support you, then please fill in the PDF on our letter of authority page.

Contact Name *

Additional information (e.g. accessibility needs, support needs etc.):

helping to make a difference

Pay with Mastercard, Visa, American Express, PayPal, Bank Transfer, Apple Pay or Direct Debit.

THAW Orkney is a Scottish Charitable Incorporated Organisation (SCO45272)

Address: *

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