Home Fire Safety Visit Request

To refer your client for a free Home Fire Safety Visit please complete this form in full.

Consent

It is necessary that your client gives you consent to pass their details to Avon Fire & Rescue Service to allow us to contact them to book and carry out a home visit. Please tick the box below to confirm the required consent has been given.

Yes, consent has been given

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Referring agency

Agency

If your agency is not included on this drop down list please send an email requesting this to This email address is being protected from spambots. You need JavaScript enabled to view it., or telephone 01179 262061 extension 229.

Your name

Email address

Telephone

Person being referred

Their full name

Address and postcode

Telephone (home)

Telephone (mobile)

Email address

Their age

85 or above

65 to 84

Under 65

Who should we contact?

Person making the request

The recipient

Other person

Full name

Telephone (home)

Telephone (mobile)

Email address

Does this person need to be present during our visit?

Yes

No

This referral

To enable us to prioritise this referral and tailor our visit to your client’s needs, please indicate below any concerns you have regarding their potential risk from fire in the home. Please select any of those that apply, and provide additional information in the box below.

Health and wellbeing

Signs of risk in the home

Other

Unable to escape unaided if there is a fire

Single parent with children under the age of 5

Lives alone

Please provide any additional information you feel is relevant and which might assist us when arranging or carrying out our visit.

Is there any risk to lone working staff?

No

Yes

Please provide details of risk to lone workers below

Thank you

Please check the information you have provided before clicking on submit

Data Protection/GDPR: Your client’s privacy is important to us and the information you provide on this form will be stored in accordance with current data protection legislation and only used for the purpose of arranging and carrying out a home fire safety visit. If you require further information about how we use and store data please contact us on 0117 9262061 or see our Privacy Notice.

For agency use only

To refer your client for a free Home Fire Safety Visit please complete this form in full.

Consent

Referring agency

Person being referred

This referral

Thank you

Other ways to request a free Home Fire Safety Visit