Introduction

Bedfordshire Fire and Rescue Service's Safe and Well visits help protect communities by providing safety advice to those most at risk. Each Safe and Well visit includes fire safety advice and additional guidance on health, wellbeing and crime prevention. If hazards or risks are identified during the Safe and Well visit, the Service can make a referral to appropriate partner agencies for further help and support.

If you would like to refer yourself or someone else for a Safe and Well visit please complete the below referral form by clicking next page.

If you are making this referral on behalf of someone else please ensure that you have their consent to do so.

Referrer Information

Are you making this referral for yourself or someone else?
Please select an answer

Personal Consent

By taking part in this Safe and Well form, you acknowledge that the details you are providing us are your own and are not of another individual.
Please confirm you are submitting your own details

Gather Consent

If you are making this referral on behalf of someone else it is important that you tell them you are doing
so. If you do not have their consent, we will be unable to process this application. Please obtain
their consent before continuing. 

The person I am referring for a Safe and Well visit has given me their consent to do so
We need the person you would like us to visit to provide consent

If you do not have their consent but you are concerned for their safety, please call us on 01234 845000 so that we can provide advice.

Referrer Information

Are you making a personal referral or a referral on behalf of a professional agency?
Please select the type of referral.

Personal referral

Personal Relationship
Please select your relationship

Professional referral

Please select the name of your organisation. If your organisation is not listed, please select "Other Agency or Professional".
Please select the referral agency or professional
If Other, please enter the name of the Agency or Professional

Your information

Title
Please enter a title
Forename
Please enter a forename
Surname
Please enter a surname
Telephone
Please enter a telephone number
Email
Please enter email address

Contact Information

Occupier Name
Please enter the occupier name
House Name/Number
Please enter an answer for this question
Street Name
Please enter a street name
Town
Please enter a Town
Postcode
Please enter a postcode
Telephone
Please enter a telephone number
Email Address
Data use
Please confirm you agree to the use of this data
Would you prefer the Safe and Well visit is arranged with someone other than the occupier?
Please select visit preference

Arrange the visit with another person

The Safe and Well visit is to be arranged with someone other than the occupier please enter their details here. Please notify them that they will be contacted by personnel from Bedfordshire Fire and Rescue Service and the reason why.

Contact name
Please enter the contact name
Contact number
Please enter the contact number

Household Risks

Are candles/tea lights or other naked flames used?
Please select an answer
Does anyone in the household smoke?
Please select an answer
Does anyone regularly use emollient creams such as E45?
Please select an answer
Does anyone use an air pressure mattress?
Please select an answer
Does anyone in the property use oxygen therapy/ cylinders?
Please select an answer
Is there any evidence of hoarding or excessive clutter?
Please select an answer
Are portable heaters used?
Please select an answer
Has there been previous fire or near miss? (e.g. Scorch marks visible)
Please select an answer
Is there a history or risk of fire setting? (e.g. child fire setting or arson attack)
Please select an answer
Are there concerns about cooking practices? (e.g. deep fat frying, cooking left unattended)
Please select an answer
Are there any electrical safety concerns? (e.g. overloaded extension leads, damaged wiring, electric blankets etc.)
Please select an answer

Reduced ability to react to an alarm or escape in case of fire

Does anyone have a reduced ability to react to an alarm or escape in case of fire?

Does the householder live alone?
Please select an answer
Are they aged 65 or older?
Please select an answer
Does anyone have restricted mobility, frailty, history or risk of falls?
Please select an answer
Does anyone have blindness, deafness or impaired hearing/ vision?
Please select an answer
Is anyone bed, chair or housebound?
Please select an answer
During an emergency would anyone be unable to unlock front door to escape?
Please select an answer
Does anyone have a mental impairment? (e.g. memory, dementia, depression etc.)
Please select an answer
Are internal doors missing or left open at night?
Please select an answer
Does anyone use alcohol regularly that may impair alertness?
Please select an answer
Does anyone use medication or substances that may impair alertness?
Please select an answer

Smoke Alarms

Does the household have no working smoke/heat alarms?
Please select an answer
Are the concerns that there are too few working smoke/heat alarms? (e.g. alarm may not operate or be heard in all areas)
Please select an answer
Are there solid fuel/gas appliances with no Carbon Monoxide alarm? (e.g. wood burners, boiler, gas fire)
Please select an answer

Additional Information

If you have any further information please add it below

Thank you for taking the time to make a referral to Bedfordshire Fire and Rescue Service. We will use the information that you have provided to arrange a Safe and Well visit.