Decluttering Intake Form
Name
First Name
Last Name
Pronouns
Phone Number
What neighborhood or suburb is the home you want serviced in?
Address of Home You Want Serviced
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name on buzzer or buzzer code
Email
example@example.com
Number of bedrooms (please include extra rooms used for other purposes such as an office)
Number of bathrooms
How long have you lived in your home?
Do you have a live-in partner(s) and/or housemates? Please list who you live with and their relation to you.
Does your live-in partner(s) and/or housemates struggle with clutter as well? Please describe.
Has the state of the home caused any tension or conflict between you and your partner(s) and/or housemates?
Do you feel like your live-in partner(s) and/or housemates encourage or influence you in any way to keep items that you otherwise may not?
Which statement best describes your home?
There are clear walkways
No matter where you walk, you will step on something
Do you have any guns in your home?
Yes
No
I am currently at risk of (select all that apply):
Being evicted
Having my children taken away by Child Protective Services
Getting a visit from Child Protective Services
Getting a visit from Adult Protective Services
Being reported to Adult or Child Protective Services, or other agencies
Having my unit inspected
I have been diagnosed with, or suspect I have (select all that apply):
Hoarding Behaviors
ADHD
Depression
Autism
OCD
Shopping Addiction
Chronic Illness
Using the images above, please identify the level of clutter in your kitchen
1
2
3
4
5
6
7
8
9
Using the images above, please identify the level of clutter in your living room
1
2
3
4
5
6
7
8
9
Using the images above, please identify the level of clutter in your bedroom(s)
1
2
3
4
5
6
7
8
9
Using the images above, please identify the level of clutter in your bathroom(s)
1
2
3
4
5
6
7
8
9
Using the images above, please identify the level of clutter in your closets, basements, or other storage area(s)
1
2
3
4
5
6
7
8
9
What percentage of items do you feel you need to part with in order to make your home more functional?
Are there any areas of your home that are not able to be used for their intended purpose due to clutter (For instance, a table so cluttered it cannot be used to eat at or a couch so cluttered it cannot be sat on)?
Yes
No
On a scale of 1 to 10: 1 being no sentimental attachment to most items and 10 being extreme emotional attachment to most items, how much sentimental attachment to your items do you have?
On a scale of 1 to 10: 1 being no anxiety at all and 10 being extreme anxiety, how much anxiety does the idea of getting rid of things give you?
Do you feel like you bring more items into your home, through shopping or other means, than a typical person?
Yes
No
Do you currently have, or have you ever had, scarcity concerns?
Yes
No
Is your love language gift-giving?
Yes
No
Unsure
What types of items do you have the most of in your home?
What types of items are most difficult for you to part with?
Are you planning to declutter soft goods, breakable items, or both?
Soft goods
Breakable items
Both
If you are planning to declutter breakable items, are you able to collect your own boxes to box up fragile donations?
Yes
No; Please bring boxes
Would you like us to do a donation pick-up after your decluttering session?
Yes
No
Undecided
Do you have a large amount of garbage in your home?
Yes
No
Is your home squalored (very unclean)? If yes, please describe.
Is there any significant damage in your home (structural damage, leaks, major plumbing issues)? If yes, please describe.
Do you have a working toilet?
Yes
No
It is not in full working order, but is functional
Do you have any issues with hoarding human waste (human urine, human feces)? [We will still work with you, we just need a heads up!]
Yes
No
Do you have issues with hoarding animals?
Yes
No
Do you currently have any infestations?
Rats
Mice
Cockroaches
Fruit Flies
Ants
Currently have bedbugs
Have been treated for bedbugs in the last 30 days
Other
Would you like your declutterer to wear an N95 mask in your home?
Yes
No
Would you like to schedule a free, 30-minute virtual consultation? (We will have gathered all the information we need on our end from this form; However, if you have any questions, comments, or concerns that would be easier to address speaking face-to-face, we can certainly schedule you for a consultation)
Yes
No
We have a 2 hour minimum and do not recommend decluttering for more than 4 hours at a time unless it is an emergency; How long of an appointment window would you like us to allow for you?
2 hours
3 hours
4 hours
This is an emergency; I need a longer appointment
How frequently would you like to be scheduled for appointments?
As often as possible; I want to get this done ASAP
Weekly
Biweekly (every 2 weeks)
Monthly
Other
What is your availability like (remember- you must be an active participant in the decluttering process)?
Which area(s) are top-priority to get decluttered? Please list all in order of importance.
While we do not require photos, we highly recommend sending them in order to provide a more accurate estimate. Photos will never be used or shared, and will only be viewed by the owner, the branch manager(s), and the specific worker(s) that will be performing the job.
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Anything else we should know?
Are you interested in any of our other services?
Cleaning
Organizing
Body Doubling
Donation Pick-Up
Handyqueer Services
Carpet Cleaning
Digital Decluttering (emails, etc.)
Document Shredding
Car Detailing
Packing/Unpacking Help
Energetic Cleansing
Welfare Checks & Saftey Services
Trash Talk Hoarding Support Group
Dog Massages (not a Trash Friends service; We refer out)
How did you hear about us?
A therapist or outpatient program
Word of Mouth
Chicago Queer Exchange
Facebook
Instagram
Lex
Flyer
Chicago Reader
FutureU Self-Care Summit
Yelp
Other
If you were referred by an employee or current client, please tell us who!
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