Referral to Home Energy Efficiency Team
Participant details
First Name
*
Last Name
Email Address
Phone
*
Address
Preferred method of contact
Call
Text
Email
Where did you hear about us?
Word of mouth
Social media post
Flyer
Community organisation
Workshop/popup
Other
Main Concerns
Main Concerns
Comfort
High Energy Bills
Assistance with appliance upgrades
National Energy Scorecard
Information
Assistance with sustainable household scheme
Energy provider
ActewAGL
Origin Energy
EnergyAustralia
Red Energy
Amber Electric
CovaU
Elysian Energy
Energy Locals
Nectr
Powerclub
Radian Energy
ReAmped Energy
Simply Energy
Social Energy
Average electricity bills
Average gas bills
Other/comments
Background - Optional
Is English your first language?
Yes
No
What language?
Translater required?
Does the participant identify as:
Aboriginal
Torres strait Islander
Both
Prefer not to say
Does the participant identify as living with a disability?
Yes
No
Does the participant identify as being a victim survivor of domestic and family violence?
Yes
No
Is support required to engage with Vinnies?
Yes
No
Type of support:
Eligibility - Optional
Weekly household income (after tax)
$0-$199
$200-$399
$400-$599
$600-$799
$800-$999
$1000-$1199
$1200-$1399
$1400-$1599
$1600-$1799
$1800-$1999
$2000 or above
Pensioner/concession card?
Yes
No
Type of Housing:
Housing ACT
Private Rental
Community Housing
Home-Owner Occupier
Number of occupants:
Adults
0
1
2
3
4
5
6
7
8
9
Children
0
1
2
3
4
5
6
7
8
9
10
Referring organisation to complete
Organisation name
*
Worker's name
Consent for referral given
Support provided
$100 Energy Voucher (actewAGL)
Bill review (checked best plan is provided)
Concession applied to energy account
Discussed appliance upgrade options and government rebates
Called energy provider with an enquiry/issue eg participant thinks meter might be broken. energy provider booked to go check.
Other
Vinnies referral reCAPTCHA
*
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