Transportation Assistance Program Application

"*" indicates required fields

Step 1: Transportation Information

Does your client have a reliable way to transport furniture and other items from Household Goods in Acton into their home?*

Yes

Your client is not eligible for transportation assistance. To continue with the standard referral, please click here.

Does your client need Household Goods to provide at least three large essential items (mattress, sofa, dresser, dining table) and at least three additional large items (set of dining chairs, upholstered living room chair, bookcase, two or more end tables)?*

Yes

Your client is not eligible for transportation assistance. To continue with the standard referral, please click here.

Have you confirmed that there are no other resources that can help with transportation?*

For example family, friends, faith or other community groups who could help rent or drive a truck, or financial support from an agency?

Yes, I have confirmed there are no other resources

No, I have not confirmed if there are other resources

Your client is not eligible for transportation assistance. To continue with the standard referral, please click here.

Is your client moving (or recently moved) out of a shelter or other transitional housing into permanent housing (within the last 1 month)?*

Yes

Your client is not eligible for transportation assistance. To continue with the standard referral, please click here. Contact us if you would like to discuss a particular situation at transportassist@householdgoods.org.

Step 2: Agency Information

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 "Yes" below.

Yes

Please note your former agency:

Step 3: Client Information

Client First Name*

Client Middle Name

Client Last Name*

(Surname)

Client Phone Number*

SMS/TXT Confirmation

By checking this box, you agree to communication with text messages from Household Goods related to their appointment. Message & data rates may apply. Message frequency varies. Reply HELP for help and STOP to opt-out. View Terms of Service and Privacy Policy.

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

Client Address*

Address of home/apartment being furnished

Street Address/Apt # City State ZIP Code

Is your client currently living at this address?*

Yes

Please provide a move-in date.*

What floor does your client live on?

Basement

1st floor

2nd floor

3rd floor

4th floor

5th floor or higher

Single family home with multiple floors

Single family home with one floor

Other

Does the building have an elevator?*

Yes

Is there off-street parking for unloading (e.g., parking lot, driveway)?*

Yes

Total number of adults (18+ years) living in the home; please include the client:*

Please enter a number greater than or equal to 1.

Total number of children (ages 0-17) living in the home:*

Please enter a number from 0 to 9.

Please check all that apply:*

If Other, please describe:*

Language - Can your client communicate in English?*

Yes - fluent

Yes - can communicate

Other

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

Please arrange for someone who can translate for your client to attend the appointment.

Household Items Needed (check any that apply):*

What furniture and household items does your client currently have in their home?*

Step 4: Transportation Needs

How well do you know the client's needs?*

Only what they tell me, I just make referrals.

A moderate amount, I see them occasionally.

A significant amount, I work with them regularly.

How do you know that your client needs Household Goods to furnish their home? (check all that apply)*

I have seen their apartment/home

Client reported need

Another agency reported need

I have been working with the client on an ongoing basis and know their needs

I don’t know if they need Household Goods to furnish their home

If a truck rental gift card were provided, would your client (alone or with friends/family) be able to reserve the truck with a credit card, drive and unload a box truck?*

Yes

Please describe your client's current living situation:*

Moving or just moved out of a shelter or other transitional housing into permanent housing (within the last month)

Just moved from one apartment to another (within the last 2 months)

Has been living in current apartment for over 2 months

Everyone who is referred to Household Goods is low-income and needs furniture. Our Transportation Assistance Program is for people in the most extreme circumstances who are living in empty homes with no other way to obtain furniture without assistance from this program.

Please explain the special circumstances your client faces beyond being low income and in need of furniture that makes them unable to secure furniture without this assistance.*

What other resources are you applying for on behalf of your client to help them furnish their home?*

Is there anything else we should know?

Once submitted, your application for support will be reviewed by our team to determine eligibility for transportation resources. If you have any questions or do not receive an email from us within 48 hours, please email transportassist@householdgoods.org.

Transportation Assistance Program Application

Step 1: Transportation Information

Step 2: Agency Information

Step 3: Client Information

Step 4: Transportation Needs

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