ABOUT THE HOME

What type of property is this?

If other, please specify

Are you a homeowner? *

Wall type

If other wall type, please specify

What windows do you have?

If no or unsure, say - "EPC certificates need renewing every 10 years. Properties can not be sold or rented without a valid one."

ENERGY USAGE AND BILLS

How many people live in your home

Energy supply (Tick all that apply) *

If other energy supply, please specify

When is energy used most

If other usage, please specify

Do you have a smart meter

Do you monitor your energy usage? *

Have you noticed any recent changes in to your energy bills? *

Roughly how much do you spend per month on energy (electric and/or gas)? *

Aside from energy. how much do you spend per month on other utilities combined? (Broadband, mobile phones, home insurance, boiler cover) *

HEATING, COMFORT AND INSULATION

How do you currently heat your home? (Tick all that apply) *

If other, specify current heating method

What heating controls do you use? (Tick all that apply) *

If using a smart control, what brand?

What insulation does the property currently have? (Tick all that apply) *

If other, please specify insulation

EXISTING ENERGY FEATURES & FUTURE PLANNING

Do you currently have any renewable technologies installed. *

If Other, please specify technology

Would you be interested in finding out more about any of the following renewable technologies? (Tick all that apply) *

GRANT ELIGIBILITY AWARENESS

Are you aware of any available grant support for energy upgrades?

Yes

Would like more info

Other

If other, please specify awareness

Have you heard about the boiler upgrade scheme offering £7,500 towards replacing a gas boiler with a heat pump?

Do you feel anyone in the household is eligible for an energy grant?

ELECTRIC VEHICLE QUESTIONS

If no, skip next question

Would you like to explore EV home charging options or grants for home based businesses?

Yes

Maybe

PERSONALISED RECOMMENDATIONS & FOLLOW UP

Which of the following would you like more information on? (Tick all that apply) *

How would you prefer us to follow up with you? *

If you would like a follow up call, when is the best time for us to contact you?

CONTACT DETAILS

First Name *

Last Name *

Phone

Email *

Address

Street Address

City *

Postal Code *

CONSENT

We never share your details outside Clever Energy Midlands. The information is used only to help you understand your options and, with your consent, to connect you with trusted local suppliers or funders. You can withdraw consent at any time.

I am happy for Clever Energy Midlands to store my details and send me a personalised report and contact me.

I am happy to receive occasional updates and newsletters about local and national energy saving opportunities.

Signature / Initials

Clear

CLOSING LINE

Thank you very much for your time. Clever Energy Midlands helps people find trusted ways to save energy, access grants and explore renewable options. Your personalised report will be sent soon. Have a lovely day.