KFRS home safety referral form

• This form can be used by any agency to refer a person(s) to Kent Fire & Rescue Service where a risk of fire in the home has been identified. KFRS will attempt to undertake a visit for all cases referred

Personal details of client being referred

• Name

• Address
  Address

• Date of Birth

• NHS number (if known)

• Telephone number

• SWIFT / ID number

• Has the person(s) consented to the referral including the sharing of information via this form?

  Yes

  No

• Reason for referral

• Is the referral urgent

  Yes

  No

• State reason

• Are there any known risks to a lone KFRS worker?

  Yes

  No

• Provide details

Contact details for referring agency

• Name of agency

• Address
  Address

• Email

• Responsible person / case worker

• Telephone

• Date of referral

• Is feedback required

  Yes

  No

  N/A

• Return this form to: Kent Fire & Rescue Service, The Godlands, Straw Mill Hill, Tovil, Maidstone, Kent ME15 6XB
  
  Telephone: 01622 692121
  Email: home@kent.fire-uk.org