Reset project Information Form

Client Information Form

Reset Project
Today's date

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A. Identification
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
E-mail
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
May we send you a text?
May we email you?
May we call you?
May we leave a message?

About This Form – Reset Project Support Application

Thank you for your interest in the Reset Project, an initiative by Reset & Shine aimed at helping individuals and families impacted by hoarding, chronic disorganisation, and other challenges that affect their living environment. This form is designed to help us understand your unique situation and determine how we can best support you. Every answer you provide will assist us in tailoring the right type and level of support, whether it's a one-off clean, ongoing assistance, or connecting you with additional services. Please note: All questions are optional. We understand that some may feel quite personal, we ask them only to ensure we provide the most appropriate and respectful support possible. If there’s anything you don’t feel comfortable answering, you are welcome to leave it blank. Your information will be kept confidential and used solely for the purpose of assessing support through the Reset Project. If you have any questions or would prefer to speak with someone directly, feel free to contact us at.
What Happens If You're Selected for a Sponsored Clean-Up?

If your application is successful and you're selected to receive support through a Reset Project clean-up, we will need to collect a little more information to help us provide the best possible service and meet the requirements of our sponsorship program. This includes: A more in-depth assessment – This helps us better understand your needs, triggers, and any safety considerations so we can approach the clean in a way that is respectful, effective, and trauma-informed. At least one photo or content of a area in your home – Because these cleans are generously funded by sponsors, we require at least one image to share with them. This helps them see the real impact their support is making. Photos will always be used respectfully and never shared publicly without your permission. We know this part of the process can feel overwhelming, but please know it is a normal part of supporting individuals with hoarding, disorganisation, or other related challenges, and we are here to walk alongside you — not judge you.

B. Referral Information
Full Name

First NameLast Name
May I have your permission to thank this person for the referral?
C. Your Medical Care

With your consent, we can coordinate with your provider to ensure our support aligns with your existing care plan or recovery goal (Optional)
Clinic/Doctor's Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

D. How urgent does the applicant require support

Rows	Extremely urgent	urgent	semi urgent	Not urgent
Urgency of cleanup

Upload photos of your situation (Optional)

Cancelof
How long have you lived in these conditions:
Reason for Cleanup Assistance: A detailed explanation of why the applicant believes they need help with a cleanup:
E. Occupants living in house

This is to help support your application, also include any animals

Household including pets

Rows	Name	Age	Sex	Relationship
1
2
3
4

F. Health & Mental Health Information
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Is there a history of physical or emotional trauma that you've experienced?
How would you rate your current physical health?
Are you currently experiencing overwhelming sadness, grief, or depression?
Are you currently experiencing anxiety, panic attacks, or have any phobias?

G. Emergency Information
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Significant other/nearest friend or relative not living with you
K. Financial Information

Annual income determines if you meet the criteria and if insured this helps incase you are selected and anything happens or we require to write a letter of support if we come across any damage that has accrued due to hoarding or other situations. If you don't have insurance this doesn't exclude your application.
What is your annual income?
Insurance Company
Phone Number
Format: (000) 000-0000.
Policy #
Group #
Name of Insured (if other than yourself)
Address of Insured (if other than yourself)
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Any other important information you think we should know
Signature
Should be Empty:

Client Information Form

A. Identification

About This Form – Reset Project Support Application

What Happens If You're Selected for a Sponsored Clean-Up?

B. Referral Information

C. Your Medical Care

D. How urgent does the applicant require support

E. Occupants living in house

F. Health & Mental Health Information

G. Emergency Information

K. Financial Information