Test Agency Form | Household Goods

NOTE THIS FORM IS NOT TO BE USED TO SCHEDULE CLIENT APPOINTMENTS. TESTING ONLY.

Furniture Pick Up Request (2)

Fields marked with an * are required

"*" indicates required fields

Name*

First Last

Email*

Enter Email Confirm Email

Town where furniture is located:*

Acton

Boxborough

Carlisle

Concord

Littleton

Maynard

Stow

Sudbury

Westford

Other

If "Other", please let us know your town:*

Do you have at least one of the following Essential Items to donate: Mattress, dresser/bureau, couch/love seat/futon, or dining/kitchen table?*

Yes

Pickup Details

Phone*

Best number to reach you

Pickup Address*

Street Address City ZIP Code

Latest possible pick up date (MO/DAY/YEAR)

Requested pick up date (MO/DAY/YEAR)

Brief furniture description and other items:

How did you hear about Household Goods?

Donated here before

I'm a volunteer

I'm a supporter

Family/friend told me

Internet search

Other organization referred me

Other

Comments:

No "essential items" for pickup? Click Submit for information about dropping off your donations and more resources.

NOTE THIS FORM IS NOT TO BE USED TO SCHEDULE CLIENT APPOINTMENTS. TESTING ONLY.

Household Goods Client Referral Form (1)

Updated 8-2023

"*" indicates required fields

To schedule an appointment for your client to receive furniture and household items, please provide us with the information requested below.

Hidden

Transportation Information

STEP 1: Transportation Planning

You and your client are responsible for transporting the goods and furniture from Household Goods

Please note that Household Goods does not have a delivery service.
Before completing and submitting the referral, confirm that your client has a reliable way of getting furniture from Household Goods in Acton into their home.

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

YES. Go directly to referral form to schedule an appointment

NO. I will submit the referral when my client has a reliable way of transporting furniture and household items from Household Goods into their home.

How will the client transport their items to their home?*

We strongly encourage renting a closed box truck. A 15 foot box truck is recommended for most clients. If your client plans to use a pickup truck, trailer, or roof rack which require securing loose items, your client will need to load and secure the items without the assistance of our volunteers.

Agency/other program is providing movers

Client/client's friends or family is renting box truck

Other (please provide details)

If Other, please explain:*

Name of Mover:*

To rent a box truck, your client will need a licensed driver, credit card for the deposit and funds to pay for the truck, mileage and gas. They will also need someone to help unload the furniture.

Does your client have the resources necessary to rent, drive and unload a box truck?*

YES

NO. I will submit the referral when my client has a reliable way of transporting furniture and household items from Household Goods into their home.

Please return and complete the referral once your client’s transportation plan is complete. If helpful, feel free to download our client transportation needs checklist.
Thank you.

Hidden

Agency Information

Fields marked with an * are required.

Step 2: Agency Information

When your form is completed properly and submitted to Household Goods, you will see a Success message.
You should receive an email regarding this referral within 48 hours. If you have not received the email within this time, please email refer@householdgoods.org.

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:

Hidden

Client Information

Fields marked with an * are required.

Step 3: Client Information

Client First Name*

Client Middle Name

Client Last Name*

(Surname)

Client Address*

Address of home/apartment being furnished

Street Address/Apt # City State ZIP Code

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 include the client:*

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 (ages 0-17) living in the home:*

Enter 0 if no children are living in the home, otherwise, please enter the number of children.

Please enter a number from 0 to 9.

Number of bedrooms in the home?*

Please check all that apply:*

Veteran

Domestic Violence

Low Income

Fire/Flood

Recently Homeless/Transitional Housing

DCF/DCF Reunification

Single Parent

Over age 65

Disability

Other

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.

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

Household Items Needed (check any that apply):*

Beds (Our inventory varies and we cannot guarantee specific sizes)

Dresser or bureau

Dining or kitchen tables

Sofa

Chairs

End tables, coffee tables, bookcases

Pots, pans, dishes, glasses, silverware

Bedding

Other items needed

Schedule Your Client's Appointment

Scheduling an Appointment*

My client is flexible

My client needs specific days/times

Preferred days/time of day*

Check as many as apply:

Monday morning

Tuesday morning

Tuesday afternoon

Wednesday morning

Thursday afternoon

Friday morning

Saturday morning

Saturday afternoon

Please select a first and second choice for an appointment date followed by a preferred time of day. Appointment days are Monday through Saturday.
*** There are no Sunday appointments and no Thursday morning appointments.***

Appointment Date - first choice*

Month

Day

Year

Appointment date first choice - preferred time of day*

Note that there are NO Thursday morning appointments.

Morning (Mon-Sat; no Thu morning appointments)

Afternoon (Mon-Sat)

Appointment Date - second choice*

Month

Day

Year

Appointment date second choice - preferred time of day*

Note that there are NO Thursday morning appointments.

Morning (Mon-Sat; no Thu morning appointments)

Afternoon (Mon-Sat)

How will your client choose their items?*

In person, in Acton

Virtually using Zoom

About Cancellations and No-Shows

Cancellations and No-Shows use an appointment that could have been used by someone else to furnish their home. They also make it difficult for Household Goods to recruit volunteers to help your clients. We will only reschedule your client once unless they have an illness or true emergency.

Are you confident that your client will be able to attend their appointment with a truck large enough to take everything they need?

YES - continue with referral

NO - I will submit the referral when I can be confident that my client can attend the appointment.

Is there anything else we need to know?

NOTE THIS FORM IS NOT TO BE USED TO SCHEDULE CLIENT APPOINTMENTS. TESTING ONLY.

Household Goods Application for Transportation Assistance (1)

8-2023

"*" 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*

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:*

Veteran

Low Income

Domestic Violence

Fire/Flood

Recently Homeless/Transitional Housing

DCF/DCF Reunification

Single Parent

Over Age 65

Disability

Other

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):*

Mattress (Our inventory varies and we cannot guarantee specific sizes)

Box Spring

Bed Frame

Dresser or Bureau

Dining or Kitchen Table

Dining or Kitchen Chairs

Sofa

Upholstered Chair

Small Tables (end tables, night stands, coffee tables)

Bookcases or other shelving

Pots, pans, dishes, glasses, silverware

Bedding

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?

I agree that if my client is approved for transportation assistance:*

I will work closely with my client to ensure that they attend their appointment. If they have a virtual appointment, I will be available to assist my client so they can join the Zoom call and I will attend as well.

I agree

and*

I will ensure that all assistance received through this program will be used for the sole purpose of transporting goods from Household Goods into their home.

I agree

and*

If Household Goods arranges for a mover to deliver items to my client’s home, I will personally ensure that my client or a responsible adult is present to accept delivery.

I agree

and*

If I do not comply with these agreements, I will become ineligible to apply for this type of support from Household Goods in the future.

I agree

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.

What is a transportation plan?

A transportation plan describes how your client will move furniture and household goods from our showroom in Acton, MA to and into their home on the appointment day.

A good transportation plan includes:

a secured vehicle appropriate for transporting items,
a committed and licensed driver, and
available labor to unload and move goods into the clients home.

These resources may be provided by the referring agency, another program or the client themselves. Regardless of who is providing the transportation and moving resources, planning in advance helps ensure clients get the goods they need.

Furniture Pick Up Request (2)

Pickup Details

Household Goods Client Referral Form (1)

Transportation Information

STEP 1: Transportation Planning

You and your client are responsible for transporting the goods and furniture from Household Goods

Agency Information

Step 2: Agency Information

Client Information

Step 3: Client Information

Schedule Your Client's Appointment

About Cancellations and No-Shows

Household Goods Application for Transportation Assistance (1)

Step 1: Transportation Information

Step 2: Agency Information

Step 3: Client Information

Step 4: Transportation Needs

What is a transportation plan?

Donate

Volunteer

Receive

About Us

Contact

Address