Climate Safe Homes
Expression of Interest

Climate Safe Homes supports people with chronic health issues to live in a healthier, more energy efficient home that's warmer in winter and cooler in summer. It can also help lower energy bills, make your home more comfortable and keep greenhouse gas emissions down.

If you are eligible and receive a place in the program, we will:

assess your energy upgrade needs, check you are eligible to participate in this program and identify the energy upgrades that are suitable for you and your home, and
where appropriate, provide a subsidy for an upgrade, which may include efficient heating, cooling, rooftop solar or ceiling insulation.

Filling out this Expression of Interest form does not guarantee a place in the program and people who submit one are free to opt out before starting the program.

All program participants will need to meet the eligibility requirements. We are also seeking a diverse representation of households and will select participants based on a variety of factors including: geographic location, number and age of people in your home, types of health conditions, type of dwelling and types of upgrades needed.

If you are not eligible for this program we may alert you to other programs, which may be suitable for you.

We will use the information we collect to help assess your eligibility and the best options for your home. Please complete this form in as much detail as possible.

If you need an interpreter or any help to fill out this form, please call 91125398 or email climatesafehomes@bsl.org.au

The Brotherhood of St Laurence (BSL) is collecting this information, via Snapforms, to assess your eligibility, to enable project delivery and to acquit the program. It will be stored securely in accordance with our privacy policy available at: https://www.bsl.org.au/privacy-policy/ . If you need to change any details or would like more information, contact us directly at E: climatesafehomes@bsl.org.au or 91125398

COMPLETING THIS FORM

Who is Completing This Form? *

I am completing it for myself or someone I live withI am completing it for someone I do not live with

Please enter your details in the "Referring Person" fields below and complete the rest of the form as if you were the person you are referring.

We will still require the actual person being referred to e-sign this form on the last section, so please make sure they are available. You can save your progress as you go if you need to come back to the form later so they can sign it.

Referring Person First Name *

Referring Person Last Name *

Referring Person Mobile *

Referring Person Email *

Someone from Climate Safe Homes will contact you to confirm the details provided in this form and discuss your needs and options in the program. Do you require a support person to be included on this call? *

YesNo

Support Person First Name

Support Person Last Name

Support Person Mobile

Support Person Email

PERSONAL DETAILS

First Name *

Last Name *

Mobile *

Will you be residing at your current address for the next 2 years?

YesNoDont Know

Is this email address regularly checked?

YesNo

Date of Birth

Main Language Spoken At Home

GP / Doctor's Name (and Practice / Clinic Name)

Hospital Name

Community Health Centre Name

Brotherhood of St Laurence PROGRAM name:

If 'Other', please specify:

ALTERNATE CONTACT DETAILS

Who should we contact if we are having trouble reaching you?

First Name

Last Name

Mobile

Relationship to you (eg: health worker, friend, family member)

ELIGIBILITY

To be eligible for Climate Safe Homes, a member of the household where the upgrades will take place needs:

- an eligible health condition, and

- an eligible concession card, and

- a need for the energy efficiency advice / upgrades provided in the program

If you have an eligible health condition, we will contact you with a form for your doctor to complete and return

Thank you for your answers, however, they do not meet the eligibility for Climate Safe Homes.

Feel free to continue completing the form below, so we can contact you if future programs become available.

Please also feel free to contact us if you have any questions about this by email: climatesafehomes@bsl.org.au or mobile: 0439 503 350

Are there working rooftop solar panels? *

YesNo

Is the heating / cooling in the main living area working well and is affordable to run? *

YesNo

GENERAL HEALTH

Additional Health Details (optional)

YOUR HEALTH TODAY

We would like to know how good or bad your health is TODAY

On the right, you will see a scale numbered 0 to 100, with 0 meaning the worst health you can imagine, and 100 meaning the best health you can imagine.

Please indicate below where you would rate your health TODAY

Clear drawing

How would you rate your health TODAY? *from 0 to 100

© EuroQol Research Foundation. EQ-5D™ is a trade mark of the EuroQol Research Foundation. Australia (English) EQ-5D-5L

Anxiety / Depression

I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed

HOUSEHOLD ADDRESS

Household Physical Address *

Street address *

Suburb *

State *

Postcode *

Postal Address Same As Above

Household Postal Address *

Address details *

Suburb *

State *

Postcode *

HOUSEHOLD DETAILS

If 'other', please describe *

What type of dwelling is your home?

freestanding houseunit / townhouseapartment / flatother

Is the dwelling part of a Body Corporate or Owners’ Corporation?

YesNoDont know

If other, please describe *

HOUSEHOLD MEMBER 2

First Name

Last Name

Mobile

HOUSEHOLD MEMBER 3

First Name

Last Name

Mobile

HOUSEHOLD MEMBER 4

First Name

Last Name

Mobile

HOUSEHOLD MEMBER 5

First Name

Last Name

Mobile

HOUSEHOLD MEMBER 6

First Name

Last Name

Mobile

HOUSEHOLD MEMBER 7

First Name

Last Name

Mobile

HOUSEHOLD MEMBER 8

First Name

Last Name

Mobile

HOME TEMPERATURES

Which is the main living space of your home? (the area you spend most time in during the day) *

If you were going to upgrade the heating and/or cooling in ONE room of your home, which room would it be?

About how many years old is the insulation? (best guess)

Over winter, is your home colder than you would like?

yes every dayyes at least half the daysyes only some daysno

Over summer, is your home hotter than you would like?

yes every dayyes at least half the daysyes only some daysno

If 'other', please describe ...

HOME HEATING

Does this main living space have heating?

YesNo

Does it heat the space well enough for you?

YesNoDont Know

If 'other' please describe

What do you currently do to keep warm inside your home on a cold day?

Details (optional)

HOME COOLING

Does the main living space of your home have cooling?

YesNo

Does it cool the space well enough for you?

YesNoDont Know

If 'other' please describe...

What do you currently do to keep cool inside your home, on a hot day?

Details (Optional)

ENERGY BILLS

Which of the following energy bill concessions do you receive?

Does your current use of heating and/or cooling lead to high electricity and/or gas bills?

YesNoDont Know

To understand your energy needs and to help identify the best energy upgrades for your home, please provide copies of your recent gas & electricity bills (one bill is sufficient, a full year is best). Please advise how you will send them, or upload a copy below. Please send the back and front of all pages, so all rates and charges are shown.

How will you provide copies of your electricity and gas bills?

I will upload copies belowI will email copies to climatesafehomes@bsl.org.auI will text copies to M: 0439 503 350I will post copies to Climate Safe Homes 67 Brunswick Street Fitzroy 3065I will contact you on P: 9112 5398 to discuss

Upload bill copies here

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NEXT STEPS

Why do you want to join the Climate Safe Homes program? *

Any other comments (optional):

We strive for our programs to be inclusive and accessible, to support all individuals to be fully involved. Do you have any needs that we should know about, to help make the most of your participation in Climate Safe Homes?

Would you like Climate Safe Homes to contact you to provide information for you to make the most of your energy efficiency upgrades? *

YesNo

Do you give consent for the Brotherhood of St Laurence to use information you share in this Expression of Interest and program participation (with no name, contact details or anything that could identify you) to advise project partners and funding bodies about the types of households that benefit from programs like Climate Safe Homes and what is needed for those that do not meet the eligibility criteria? *

YesNo

You are free to choose 'no' and it WILL NOT affect your eligibility for the program in any way

Do you want to join our contact list? If so, we will keep this Expression of Interest form and contact you when further programs become available that you may be eligible for *

YesNo

As you are completing this form on behalf of someone you do not live with, please ensure they sign below

Signature: *

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