Professional Referral Form — Hoarding Helpers

This is the printable / downloadable referral form. Use your browser's print function to save as PDF or print.

Professional Referral Form

For use by housing officers, social workers, OTs, NHS teams, insurance handlers, and other professionals. All fields marked * are required.

Professional referrals only. This form is for use by professionals referring clients on behalf of their organisation. If you are a member of the public seeking support for yourself or a family member, please call us on 0118 449 0917 or email info@hoardinghelpers.co.uk.

Section 1 — Referrer Details

Full name *

Work email address *

Organisation / team *

Job title / role *

Work phone number *

Extension (optional)

Preferred contact method

Phone

Either

How did you hear about us? (optional)

Section 2 — Client Details

Client initials *

Your client / case reference (optional)

Client first name (optional)

Client last name (optional)

Date of birth

Client phone number (optional)

Client email address (optional)

Client address *

Postcode *

Living situation

Tenure type

Property type

Lift available?

Yes

Unknown

Floor level / stairs

Parking / vehicle access

Mobility / access needs (optional)

Key holder / access arrangements (optional)

Access notes (optional)

Interpreter / language support needed?

Yes — English not first language

Yes — BSL / deaf support

Yes — other

Unknown

Section 3 — Referral Details

Services requested * (tick all that apply)

Hoarding & Declutter Sessions

Case Coordination & Management

Hospital Discharge (Bedflow)

Insurance Company Referral

Bulk Clearance

Mini Clear & Repair

Neurodivergent Friendly Support

Not sure — please advise

Urgency / priority

Routine

Urgent — within 2 weeks

Very urgent — within 5 working days

Emergency — as soon as possible

Client availability (optional)

Has the client been informed of this referral?

Yes — aware and expecting contact

Yes — aware but may be resistant

No — referral without client's knowledge

Partially — knows support is being arranged

Client consent *

Yes — client has given consent

No — safeguarding referral

Court of Protection decision in place

Consent not yet sought

Court of Protection order in place?

Yes

N/A

COP application pending?

Yes

N/A

Hospital Discharge details (complete if Hospital Discharge / Bedflow selected above)

Hospital name

Ward name / number

Proposed discharge date

Discharge coordinator / named contact

Additional discharge notes

Insurance Referral details (complete if Insurance Company Referral selected above)

Insurance company name

Claim number

Loss adjuster / handler name

Loss adjuster contact number

Loss adjuster extension (optional)

Type of incident

Date of incident

Restoration company (optional)

Insurance notes (optional)

Is the client at a temporary address?

Yes

Temporary address (if yes above)

Town / city

Postcode

Temporary address notes (optional)

Has storage been arranged?

Yes

Storage company / provider (if yes above)

Storage facility address

Town / city

Postcode

Storage contact name (optional)

Storage contact number (optional)

Storage notes (optional)

Section 3b — Room Clutter Assessment (CIR Scale)

Rate each applicable room using the Clutter Image Rating (CIR) scale: 1 = minimal clutter, 9 = severe. Leave blank if the room was not accessed or does not apply. See hoardinghelpers.co.uk/resources/clutter-image-rating-scale for the visual guide.

Room	CIR Score (circle or write: 1 – 9 or N/A)
Living room	N/A
Kitchen	N/A
Bedroom 1	N/A
Bedroom 2	N/A
Bedroom 3	N/A
Bathroom	N/A
Hallway / stairs	N/A
Garden / outdoor space	N/A
Garage / outbuilding	N/A
Other room / area	N/A

CIR scale: 1–3 mild, 4–6 moderate, 7–9 severe. See hoardinghelpers.co.uk/resources/clutter-image-rating-scale for photographic reference.

Room assessment notes (optional)

Section 4 — Risk & Health Information

Fire risk identified?

Yes

Unknown

Safeguarding concern?

Yes

Unknown

Known mental health diagnosis?

Yes

Unknown

Known neurodivergent diagnosis?

Yes

Unknown

Pets present?

Yes

Unknown

Previous allegations / complaints against professionals?

Yes

Unknown

Sharps / needles risk?

Yes

Unknown

Aggression / behaviour risk?

Yes

Unknown

Vermin / infestation?

Yes

Unknown

Self-neglect concerns?

Yes

Unknown

Substance misuse?

Yes

Unknown

Biohazard / bodily fluids?

Yes

Unknown

Section 5 — Background Information

Previous or current support in place

Safeguarding concerns — details (if safeguarding concern flagged above)

Additional information / reason for referral

Supporting photos attached? (tick if sending separately)

Yes — photos attached / sent separately

No photos available

Declaration
I confirm that the information provided in this referral is accurate to the best of my knowledge. I understand that Hoarding Helpers will use this information solely for the purpose of assessing and delivering appropriate support to the client. Where consent has been obtained, I confirm that the client has been made aware that their information is being shared with Hoarding Helpers.

Referrer signature

Date

Print name

Job title