CONCERNED ABOUT FIRE RISKS?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Do you have a poor sense of smell?
Yes No
Do you have a gas fire, hob or oven?
Yes No
Do you sometimes forgot to turn off the cooker/hob?
Yes No
Do you have a working smoke alarm?
Yes No
Can you hear your smoke alarm?
Yes No
Are you worried about the wiring in your home?
Yes No
Do you have sockets with numerous plugs in it?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No