Community Safety

Agency Referral Form

Please use this form if you are from another agency and are referring a vulnerable adult or someone who is at increased risk of fire and require Fire Service advice or Safe and Well Visit for the person.

You can find contact details for us on our Get In Touch page if you need to contact us in another way or about another matter.

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How we use your information: North Yorkshire Fire and Rescue Service (the Authority) as the data controller will process your information in line with relevant data protection laws. To find out more about how we will use the information you provide on this form and for the visit please view our Privacy Notice here: http://www.northyorksfire.gov.uk/privacy

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Complete the form below

Referring Organisation *

Name and role of person making referral *

Contact details of person making referral (including email and phone number) *

Details of person you are referring

Name of person being referred *

Telephone number of person being referred *

Address of person being referred *

Postcode of person being referred *

Age of person being referred *

Property Type (please select) *

Does the person live alone? *

Do you have consent to make the referral? (please select) *

If no is there an exemption?

Risk/Vulnerability factors relating to the person you are referring

Is there a smoke alarm or other fire detection?

Does the person display unsafe smoking habits?

Is the person at risk of arson threats?

Is there evidence of burns or scorching to carpets, furniture or clothes?

Is there a history of previous fires or near misses?

Is the person affected by alcohol, drugs or medication?

Is the person displaying signs of dementia or mental health issues that might impact on safety?

Does the person have mobility issues or are they unable to evacuate unaided?

Is there evidence of hoarding or severe clutter?

Please provide any additional relevant information

Are you aware of any potential risks to NYFRS staff if they visit the property (please detail)?

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