A Hand Up Referral Form

For any and all questions, please reach out to our team at volunteer@journeyhomect.org

***Please note, our AHU Coordinator is currently out of the office. She will review and respond to all furniture requests the week of July 14.***

HMIS Number

Does this client speak and understand English?

Client's First Name

Client's Last Name

Client's Phone Number

Phone

Secondary Number

Phone

Name & Relationship to Secondary Contact

How many kids are in the family?

How many adults are in the family? (over 18)

Client's New Address (include floor number)

Town the client moved to

Zip Code of town the client moved to

Does the building have a working elevator?

Is the client a veteran?

Can the client pick up items at the warehouse?

Was this client chronic before housing?

Has the client moved in yet?

Please do not submit a furniture request until a client has moved in and the unit has passed inspection.

Move-in Date

mm/dd/yyyy

Program Name

Case Manager Name

Case Manager's Phone Number (include extension)

Please format the phone number as XXX-XXX-XXXX Ext. XXX (ex. 123-456-7890 Ext. 321)

Case Manager's Email

Notes / Comments

Number of Twin Beds Needed

Number of Full Beds Needed

Number of Queen Beds Needed

Sheets Needed for Bed(s)

Blankets / Comforters Needed for Bed(s)

Number of Pillows

Note: We can only provide 1 per person

Number of Towel Sets Needed

Number of Sofa/Loveseats

Number of Armchair/Recliner

Number of Dressers

Number of Coffee Tables

Number of End Tables/Night Stands

Number of Kitchen Tables

Number of Kitchen Chairs

Number of Pot/Pan Sets

Number of Kitchen Sets

Each set includes 4 dishes, glasses, bowls, etc.)

Number of Lamps

Number of Coffee Makers

Number of Toasters

Number of Microwaves

Number of Fans/ACs

Number of Heaters

Number of Area Rugs

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