SPEED REFERRAL for
Weatherization
FAX: 919-872-9574
This form is intended to facilitate the referral process that you, as a professional, are undertaking on behalf of your client. If you are unsure of eligibility requirements or services offered, you must call Resources For Seniors at 919-872-7933 to speak to an Intake Specialist.
Weatherization services are designed to make a home more energy efficient and less expensive to heat and cool. This program is targeted to people under 200% of the federal poverty level, and there is no cost to the homeowner.
Is your client:
- A resident of Wake County?
- Low income?
- Living in a home that they own or rent?
The following information must be completed in its entirety. Any incomplete information will void the referral.
HINT: Use your mouse or tab key to move from one field to another. Using the Enter/Return key will cause the form to be submitted prematurely!
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: | |
| Date of Birth: | |
| Contact Person: | |
| Relationship: | |
| Contact Phone: | |
| Best time to call: | |
| Monthly HOUSEHOLD Income*: | |
| How many people in the household? | |
| Who owns the residence? |
*If client wishes to be considered for the Weatherization program, monthly income MUST be provided.
Anything else we should know? Who should we contact, client or caregiver? Are there other contact people we should know about? Any communication barriers?
| Does client own the residence? | Yes No |
If client is renting, it is his/her responsibility to obtain written permission from the landlord before Resources for Seniors may complete any work.
By making this referral, you are certifying that the above information is correct to the best of your knowledge, and that the client is aware of your actions on his/her behalf and the waiting list status of this program.
| Your Name: | |
| Organization: | |
| Your Email: | |
| Phone# where message can be left for you (no pagers, please!): |
How did you hear about RFS/HHI?