Fire Safety :: Online Client Referral Form

This form is for use by staff at organisations who wish to refer potentially ‘at risk’ clients to the Fire Services in Wales for a Home Fire Safety Check. If you are an individual and wish to request a Home Fire Safety Check please click here.

If you are making a referral using this form please read the information below. You might also find this information about how we collect data and what we do with it useful - click here

• Our office hours are 9am-5pm Monday to Thursday and 9am-3pm Fridays. Any referrals made outside these hours will not be picked up until the following working day.
• If you would prefer to fax your referral form please send it to 01633 654001 and include your name, organisation, contact number and who should be the point of contact for the Fire Service to arrange the check. The same guidelines on office hours apply.
• By sending this form you confirm you have gained the consent of your client to pass their details to Firebrake Wales and the Fire Services. You will not be able to send this form without confirming this using the tick box at the end of the form.
• The details that you send will be held securely and only will only be accessed by designated Firebrake staff.
• Our online referral form is not intended to replace any current referral processes or agreements that you may already have with the Fire Services – it is simply an additional option for you to use.
• This form is to request a Home Fire Safety Check from the Fire and Rescue Service. Please note, the check can take up to 28 days to be delivered

What is a Home Fire Safety Check?

In order for your referral to be sent to the correct Fire Service please select the region in which your client lives
If you are unsure, please use the following links: North Wales Service area, South Wales Service area, Mid & West Wales service area

Choose your regionNorth WalesSouth WalesMid & West Wales

Please complete both parts of the form to submit a referral (* indicates mandatory field)

1. Referrer's Details

Referrer's Name*

Organisation*

Address*

Post Code*

Telephone*

Email*

Relationship to client

2. Client's Details

Clients Name*

Client's Address*

Client's Postcode*

Client's Telephone Number*

Age

The following information will allow the Fire Services to fully prepare for the Check. Is there anyone in the home who is/has:

Please tick all that apply

 over 60

 hearing impaired

 deaf

 sight impaired

 registered blind

 a smoker

 an oxygen user

 under 5 years of age

 had a previous fire

 living alone

 mobility difficulties

If yes, do you think they would be able to leave the house in under 3 minutes? Select OneYesNo

 affected by a disability

please specify:

About the property

Please tick all that apply

 the property is rented

 the property is fittted with smoke alarms

if yes, do they work? Select OneYesNoNot sure

Please give any further comments / information you think would be useful e.g. risky behaviours such as smoking in bed, dementia, non-English speaking

Please confirm who you would like the Fire Service to contact to arrange the check:

 the client

 the person submitting this referral

 another named individual e.g. family member, carer

Please give details - name, contact number and relationship to client

 Please tick this box to confirm your client is happy for their details to be passed to the Fire Services and Firebrake Wales In order for this referral to be submitted please tick this box to confirm your client is happy for their details to be shared with the Fire Services (for a HFSC) and with Firebrake (for monitoring and evaluation of the service). Personal details will never be used other than in the ways stated above. You can withdraw consent at any time by contacting Firebrake Wales