Agency Referrals Form - Household Goods

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.
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*
Are you 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 necessary
Your Cell Phone Number (Agency contact)
Your Email (Agency contact)*
Enter Email Confirm Email

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
First Last
Client Address*
Street and town

Street Address City
Client Phone Number*
Number of adults (18+ years) living in the home:*
Please enter a value greater than or equal to 1.
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:*
Major appliance request
Enter request for washer, dryer or refrigerator. Be aware that major appliances are rarely available.
- Washer
- Dryer
- Refrigerator
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 an appropriate size vehicle 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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