Rise & Restore - Hoarding & Self-Neglect Support Services
Initial referral/intake for hoarding and self-neglect support services. Please complete the client details, referral information, safeguarding and risk checks, assessment tool, and consent section.
Client Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Postcode
*
Phone Number
*
Please enter a valid phone number.
Format: +44 00000 000000.
Email
example@example.com
Referral Information
Referred by
*
Self
Family
Social worker
Other
Referrer Name & Contact Details
Reason for referral
*
Living Situation & Safeguarding
Living situation
*
Lives alone
With family
Supported housing
Other
Any known safeguarding concerns?
*
Yes
No
If yes, provide details
Immediate Risks
Fire risk
*
Yes
No
Trip / Fall hazards
*
Yes
No
Hoarding severity concerns
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Yes
No
Self-neglect concern
*
Yes
No
Property Condition Checklist
Blocked exits or doorways
Yes
No
Piles of items causing trip hazards
Yes
No
Rotting food / waste accumulation
Yes
No
Evidence of vermin
Yes
No
Damp / mould
Yes
No
Limited access to kitchen / bathroom
Yes
No
Hoarding & Self-Neglect Assessment Tool
A. Clutter Level Assessment
*
Level 1 – Clean and functional living space
Level 2 – Some clutter, all rooms still usable
Level 3 – Clutter in some rooms, limited use of space
Level 4 – Significant clutter, furniture hard to access
Level 5 – Rooms unusable, pathways restricted
Level 6 – Major blockage, hygiene concerns emerging
Level 7 – Severe hoarding, health & safety risk
B. Self-Neglect Indicators
Poor personal hygiene
Missed medical appointments
Poor nutrition / food access concerns
Lack of heating or utilities use
Social isolation
Overall Risk Level
*
Please Select
Low
Medium
High
Critical
Professional Judgment Summary Notes
Primary Concern Identified
Immediacy of Intervention Required
*
Routine (within 2–4 weeks)
Soon (within 7 days)
Urgent (within 48 hours)
Immediate (same day response)
Recommended Next Steps
Client Consent for Support & Information Sharing
I agree to receive support from Rise & Restore Hoarding & Self-Neglect Service. I understand that:
Information Sharing with Social Services
*
Yes
No
Information Sharing with GP / health professionals
*
Yes
No
Information Sharing with Fire and rescue service (if risk identified)
*
Yes
No
Information Sharing with Other agencies involved in my care
*
Yes
No
Information will only be shared when necessary to:
- Protect my safety
- Reduce risk in my home
- Support my health and wellbeing
Photographs consent: I consent to photographs being taken for assessment and progress purposes only.
*
Yes
No
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: