Environmental Health Residential Complaint / Enquiry form
Address
Postcode
Phone
Email
White
North African, Arab, Iranian
Black or Black British
Mixed
Asian or Asian British
Chinese
Other
Other Client Details
Details of initial contact (If different from above)
Any Children under 16
House Tenure
Private Rented
Owner-occupied
Housing Association
Council Tenant (this service does not deal with Council properties)
Reason for referral
Is the client's health most at risk from
Pest infestation
Disrepair
Overcrowding
Cold Home
Damp Home
The reason for this is (optional)
Do you need an interpreter?
Yes
No
How did you hear about our service?
Other Comments Box
Details of referrer (optional)
Name
Organization
Telephone
E-mail
Client agrees to referral (Please tick)
