Your details

The details of the person making the referral to us

First Name *Enter your first name

Last NameEnter your last/family name

Email Address *Enter a contact email address for you

Phone *Enter your contact number

Are you a partner or stakeholder of West Midlands Fire Service? *YesNo

What is your relationship to the occupier who needs the visit? *If you have a personal or professional connection to the occupier, please tell us here

Ok, who you do work for? *

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What is your role/position?

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If you have a member/partner ID number, please enter it here

The occupiers details

Please provide the details of the individual who needs the visit

First Name *Enter the occupiers first name

Last Name *Enter the occupiers last/family name

Phone *The phone number of the occupier that needs the visit

Occupiers date of birth *

Enter the date of birth of the occupier

Do you want us to contact you, or the occupier directly, to book the appointment? *Contact me pleaseYou can contact the occupier directlyWe need to know who to speak to to book the appointment

Do you have the consent of the occupier to share their details with us? *Yes, I have their consent to share their detailsNo, I do not have the occupiers consent

Why don't you have their consent? *

If you simply haven't asked, please do so before going further. If there is a reason related to the occupier's physical, mental or personal circumstances, please specify this here.

Details of the property you want us to visit

Street Address *Enter the property name/number and road name.

City *Enter the city

Area *

Postcode *Enter the full property postcode

Is the property owned or rentedProperty is owned by me/the occupierThe property is rented

Risk questions

These help us to prioritise those who need a visit most, please answer them as honestly as possible

Does the property have working smoke alarms? *YesNoIf you have some but they are broken or don't have batteries, choose no.

Is anyone living in the property deaf or very hard of hearing? *YesYes, and a British Sign Language interpreter will be requiredNo

Does the main occupier live alone? *YesNo

Are any occupiers single parents, with a child under 18? *YesNo

Is anyone in the property of working age but has been unemployed for more than 1 year? *YesNo

Does anyone living in the property smoke? *YesNo

Does anyone in the property have mobility issues that would prevent or slow escape if there was an emergency? *YesNo

Is anyone living in the property a regular user of alcohol or other substances? *YesNo

Is medical oxygen in use in the property? *YesNoIf it isn't yet, but is planned to be soon, select yes.

Any other comments or notes about the property or anyone living in the property?0 / 2000

The bit about data

You need to know how we deal with data, this section lets you know how we use yours.

At West Midlands Fire Service we take privacy seriously never share your personal data unless you agree or we are legally required to do so. For further information about how we use information collected for a safe and well visit and how we maintain the security of information, including your rights to access information, please see our privacy policy. *

I agree with my data being used in accordance with West Midlands Fire Service's privacy policy and website terms and conditions.

Who is the safe and well visit for?

Our safe and well referral forms are to inform us of a non-urgent visit where we can fit smoke detectors and give advice on fire safety in the home. If the matter life-threatening, please dial 999 or if not an emergency but very urgent, call 03300 589 000.

Safe and well visits are only available for non-business properties in the West Midlands areas. For safety checks outside of our area, please contact your local fire service. To submit your details to us, just complete the correct form below and a member of our team will be in touch!

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