Making A House A Home Referral Form
If you have any questions, please contact our Furniture Program Coordinator at 860-808-0336.
HMIS Number
*
https://ecm.cthmis.com/cceh.ecm
Client's First Name
*
Client's Last Name
*
Client's Phone Number
*
Secondary Number
A family member, friend or neighbor whom we will be able to reach if client's phone is lost/stolen/out of minutes.
Name & Relationship to Secondary Contact
How many kids are in the family?
*
How many adults are in the family? (over 18)
*
0
1
2
3
4
5
6
7
8
9
10
Client's New Address (include floor number)
*
Town the client moved to
*
Does the building have a working elevator?
*
Yes
No
Is the client a veteran?
*
Yes
No
Can the client pick up items at the warehouse?
*
Rent a van/truck, have a friend with a van/truck, or does the agency have a van/truck/or funding to use for client assistance.
Was this client chronic before housing?
*
Yes
No
Move-in Date
*
Program Name
*
Case Manager Name
*
Case Manager's Phone Number (include extension)
*
Case Manager's Email
*
Date Submitted
*
Number of Twin Beds Needed
*
0
1
2
3
4
5
6
7
8
9
10
Number of Sheet Sets Needed and Size
*
Number of Blankets/Comforters Needed
*
Number of Pillows
*
one per person
0
1
2
3
4
5
6
7
8
9
10
Number of Towel Sets Needed
*
one per person
0
1
2
3
4
5
6
7
8
9
10
Number of Sofa/Loveseats
*
0
1
2
3
4
5
6
7
8
9
10
Number of Armchair/Recliner
*
0
1
2
3
4
5
6
7
8
9
10
Number of Dressers
*
one per person
0
1
2
3
4
5
6
7
8
9
10
Number of Coffee Tables
*
0
1
2
3
4
5
6
7
8
9
10
Number of End Tables/Night Stands
*
0
1
2
3
4
5
6
7
8
9
10
Number of Kitchen Tables
*
0
1
2
3
4
5
6
7
8
9
10
Number of Kitchen Chairs
*
0
1
2
3
4
5
6
7
8
9
10
Number of TV Stands
*
0
1
2
3
4
5
6
7
8
9
10
Number of Pot/Pan Sets
*
0
1
2
3
4
5
6
7
8
9
10
Number of Dish Sets (each set includes 4)
*
0
1
2
3
4
5
6
7
8
9
10
Number of Glass Sets (each set includes 4)
*
0
1
2
3
4
5
6
7
8
9
10
Number of Cooking Utensil Sets
*
0
1
2
3
4
5
6
7
8
9
10
Number of Lamps
*
0
1
2
3
4
5
6
7
8
9
10
Number of Coffee Makers
*
*Limited quantity received – may not be available at time of delivery.
0
1
2
3
4
5
6
7
8
9
10
Number of Toasters
*
*Limited quantity received – may not be available at time of delivery.
0
1
2
3
4
5
6
7
8
9
10
Number of Microwaves
*
*Limited quantity received – may not be available at time of delivery.
0
1
2
3
4
5
6
7
8
9
10
Number of Fans/ACs
*
*Limited quantity received – may not be available at time of delivery.
0
1
2
3
4
5
6
7
8
9
10
Number of Heaters
*
*Limited quantity received – may not be available at time of delivery.
0
1
2
3
4
5
6
7
8
9
10
Number of Area Rugs
*
0
1
2
3
4
5
6
7
8
9
10
Notes / Comments
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Email address
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