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*

Client Email Address

**We collect this info in order to send clients an appointment reminder email and for 'remote zoom' meeting code if needed. **

Enter Client Email Confirm Client Email

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

Please enter a number 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.

Age/Gender of each child living in the home:*

Please list the ages and gender of the children living in the home (i.e., girl, 14; boy 5):

Please check all that apply:*

If Other, please describe:*

Language - Can your client communicate in English?

Our volunteers call to confirm appointments and are also able to help with questions about their order.

Yes - fluent
Yes - can communicate
No

Language

If the client is non-English speaking, what language do they speak:

Major Household Items Needed (check any that apply):*

No need to list small items

Beds
Bureau
Dining or Kitchen Tables
Sofa
Other

If Other, please describe.*

No need to list small items.

Mattress size(s) needed:*

Each family is allowed one Queen or one Full mattress. Other family members can receive Twin or Twin XL.

Queen
Full
Twin
Twin XL

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 NOTE: We have recently changed our client shopping method to real time video shopping via Zoom with a volunteer client assistant. Clients are given tablets while staying in their trucks so volunteers can help clients shop virtually. Let us know if you need more info about this change so you can inform your client.

Please select your client's first and second appointment date & time choice. Appointment times are Monday, Tuesday, Wednesday, Friday: 9AM, 10AM & Tuesday, Thursday, Saturday: 1 PM, 2PM (Closed SUNDAYS).

Appointment Date & Time - First Choice*

Please provide a date & time (Appointments are Monday, Tuesday, Wednesday, Friday: 9AM, 10AM & Tuesday, Thursday, Saturday: 1 PM, 2PM (Closed SUNDAYS).

Appointment Date & Time - Second Choice*

Please provide a date & time (Appointments are Monday, Tuesday, Wednesday, Friday: 9AM, 10AM & Tuesday, Thursday, Saturday: 1 PM, 2PM (Closed SUNDAYS).

Will client select their items in person or remotely?*

Will your client be at Household Goods for their appointment, or will they need to use REMOTE ZOOM (i.e. if movers are scheduled or for other reasons where client cannot come to Acton).

In person, with or without movers
Remote Zoom (using movers)
Remote Zoom (other reason)

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.

Our volunteers will load a box truck but not personal vehicles. These would need to be loaded by the client.

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 date & time and remind them to bring a vehicle large enough for items selected. We can only load box trucks; private vehicles may need to be loaded by clients.*

Please check "yes" to agree:

Yes

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