If you need any help with this form, you can call us on 0808 801 0828 or email Disability.EnergySupport@scope.org.uk.
You need to get the person's consent before you apply for the service for them.
Disability Energy Support is a service for disabled people or households where 1 or more disabled people live.
There is advice for dealing with your gas, electricity and water bills on our website.
Disability Energy Support is only available to people living in England and Wales.
Register for Disability Energy Support