A Hand Up Referral Form

A Hand Up Referral Form

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

HMIS Number*

Does this client speak and understand English?

Select

What is this client’s primary language?*

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?*

Select

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

Select

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?*

Select

Is the client a veteran?*

Select

Can the client pick up items at the warehouse?*

Was this client chronic before housing?*

Select

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.

Select

Move-in Date*

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

Select

Number of Full Beds Needed

Select

Number of Queen Beds Needed

Select

Sheets Needed for Bed(s)

Select

Blankets / Comforters Needed for Bed(s)

Select

Number of Pillows

Note: We can only provide 1 per person

Select

Number of Towel Sets Needed

Select

Number of Sofa/Loveseats

Select

Number of Armchair/Recliner

Select

Number of Dressers

Select

Number of Coffee Tables

Select

Number of End Tables/Night Stands

Select

Number of Kitchen Tables

Select

Number of Kitchen Chairs

Select

Number of Pot/Pan Sets

Select

Number of Kitchen Sets

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

Select

Number of Lamps

Select

Number of Coffee Makers

Select

Number of Toasters

Select

Number of Microwaves

Select

Number of Fans/ACs

Select

Number of Heaters

Select

Number of Area Rugs

Select

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