Household Goods | Agency Referrals Form

Client Referral Form

1 Agency Information

2 Client Information

To schedule a client visit, please provide us with the following information

If you do not receive an email from us within 24-48 hours, please contact us at refer@householdgoods.org to ask if we received your referral request. Note, if you're a new agency, it may take longer for us to reply as we need to set your agency up in our system.
When your form is completed properly and submitted to Household Goods, you will see a Success message.
Agency Information
Fields marked with an * are required.
Your Name (Agency Contact)*
First Last
Your Title or Staff Position*
Please let us know if you are an intern/temp or volunteer.
Name of Your Agency*
Include program name if applicable
Your Agency Address*
Please provide street, city, zip code

Street Address City State ZIP Code
Agency Website
Your Office Phone Number (Agency contact)*
Please provide extension if applicable
Your Cell Phone Number (Agency contact)
Your Email (Agency contact)*
Enter Email Confirm Email
Have you changed agencies?
If you've previously submitted client referral requests through a different agency, please check the box below.
- Yes

Client Information
Fields marked with an * are required. "If you do not receive an email from us within 24-48 hours, please contact us at refer@householdgoods.org to ask if we received your referral request. When your form is completed properly and submitted to Household Goods, you will see a Success message.
Client First Name*
Client Middle Name
Client Last Name*
Name of 2nd adult in household
Second Adult First Name Second Adult Last Name
Client Address*
Street and town

Street Address/Apt # City
Client Phone Number*
Total number of adults (18+ years) living in the home:*
Please enter a value greater than or equal to 1.
Total number of children (0-17) living in the home:*
Enter 0 if no children are living in the home, otherwise, please enter the number of children.
Major household items needed:*
No need to list small items.
Please note we no longer accept special requests for large appliances (washer, dryer, fridge) due to very low donations.
Schedule Your Client's Appointment

Please select your client's first and second appointment date choice. Remember that Distribution Hours are Mondays, Wednesdays, Fridays from 9am-11am, and Tuesdays, Thursdays, Saturdays and Sundays from 1pm-3pm.
Appointment Date - First Choice*
Appointment Date - Second Choice*
How will your client transport the items to their home?*
- Agency providing movers
- Client renting box truck
- Other
If "Other", please describe:
Mover's Name
If the agency will schedule a moving service, enter the mover's name here.
Additional Comments
I understand items at Household Goods are gently used, donated by the community, and will inform my client before making an appointment.*
Please check "yes" to agree:
- Yes
I agree to notify my client about a confirmed appointment and remind them to bring a vehicle large enough for items selected since all items must be picked up on the same day as the appointment.*
Please check "yes" to agree:
- Yes

Client Referral Form

Agency Information

Client Information

Schedule Your Client's Appointment

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