Household Goods | Agency Referrals Form

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*

(Surname)

Client Address*

Street and town

Street Address/Apt # City State

Client Phone Number*

Total number of adults (18+ years) living in the home:*

Please enter a value greater than or equal to 1.

Second Adult in household - First Name

Second Adult in household - Middle Name

Second Adult in household - Last Name

(Surname)

Please list First and Last Names of other adults:

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.

Please check all that apply:*

If Other, please describe:*

Major household items (beds, bureaus, dining or kitchen tables, sofa) 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

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