Monmouthshire Referral Form

This form is for MONMOUTHSHIRE referrals only. For Newport please use the Newport gateway only and for Caerphilly residents please use the designated Caerphilly referral form. For all other enquiries please contact us via our e-mail address info@holistic-hoarding.co.uk Please fill out the referral form with as much detail as possible For Private consultations please contact us directly via email.

Details of the Referrer

Referrer's Name

First Name Last Name

Organisation

Role/ Relationship

Phone

Date submitted

Details of the person being referred

Name

First Last

Address

Street Address Address Line 2 County Post Code Country

Phone

Date of birth

NI Number

Gender

Male

Female

Non-binary

Prefer not to say

Assessment Information

Reason for referral

(please use this space to outline the current situation at the property with as much detail as possible)

Please outline any previous interventions directly related to hoarding that may have been offered to the individual

(eg, Clean and Clear, counselling).

Please provide details of any concerns you may have about the property

(eg, risk of eviction or ongoing Child Protection Proceedings).

Please provide details of any risks that may be associated with the individual or the home / anyone else living at the home.

Does the individual have any co-occurring mental or physical health conditions? Please provide details if known.

Are you aware of any motivating factors that may encourage the individual with the support process

(eg, does the individual wish to move?)

Would the individual like any information on our peer-led support group that runs each month?

Thank you for taking the time to provide this information.

A full assessment will be carried out, and you will be updated of all outcomes regarding this. Holistic Hoarding will work on a needs-led basis with 10 individuals at a time – referrals will be prioritized according to urgency (in particular, those threatened with eviction or where children reside at the home) and a waiting list system will operate for all other cases.