Household Goods Client Referral Form "*" indicates required fields To schedule an appointment for your client to receive furniture and household items, please provide us with the information requested below.HiddenTransportation InformationSTEP 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. HiddenAgency InformationFields marked with an * are required. Step 2: Agency InformationWhen 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 email@example.com.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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 No Please note your former agency: HiddenClient InformationFields marked with an * are required. Step 3: Client InformationClient First Name* Client Middle Name Client Last Name*(Surname) Client Address*Address of home/apartment being furnished Street Address/Apt # City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 No 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 neededSchedule 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 (Must have movers picking up at the time of the appointment) 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?