Agency Referral Form - Household Items
*****PLEASE READ***** Please provide the information below for your client. You will be contacted via email or telephone when the items are available. Please note that there is currently a waitlist for beds, couches, and dining tables. Your client will be placed in line. All furniture and household goods are 100% donation-based, so we cannot determine a timeframe for the waitlist. Please note that items are subject to availability. All household goods and furniture are pre-owned.
Name of Your Agency
Agency Website
Your First Name (Agency Contact)
Your Last Name (Agency Contact)
Your Title (Agency Contact)
Your Email (Agency Contact)
Your Phone Number (Agency Contact)
How did you hear about us?
Website
Social Media
Other
Please check all applicable as it pertains to your client's qualification for household items
Low income
Senior
Disability
Transitional Housing/Previously Homeless
Refugee
Fire or Natural Disaster
Domestic Violence
Alcohol/Drug Recovery Program
Other
Please State - if other
Has client received services from us in the past? (Check for Yes)
First Name (Client)
Last Name (Client)
Address (Client)
Phone Number (Client)
# of Adults in the household
# of Children in the household (Type "0" if none)
Ages of Children, if any (separate by comma)
How will your client pick up household items and bring to their home? COA does not provide transportation of any means.
Client will have their own transportation large enough to hold all necessary items.
Agency will provide transportation
Other
Household Income (Annual or Monthly)
Verification of Income (Statement, W2, Paystub, etc.)
EBT Eligible? (Check for Yes)
Kitchen
Plates
Cups
Silverware
Skillets
Pots
Livingroom (there is currently a waiting list for sofas and loveseats)
Sofa
Loveseat
Lamp
Coffee Table
Livingroom chair
Dining room (there is currently a waiting List for tables)
Dining table and chairs
Bedroom (there is currently a waiting List for all beds)
Twin Bed
Full Bed
Queen Bed
King Bed
Toddler Bed
Notes
There is currently a waiting list for beds, couches, and tables. If the client has waited longer than 3 months, you must re-apply. All furniture is Pre-owned.
For general questions, call 562-432-1440. Once your referral is processed, and we have the requested furniture available, we will contact you or the client to confirm a date and time for pick up. Please let your client know to be prepared with a vehicle for picking up large items. Please have your clients give advanced notice of cancellation or rescheduling. Clients are allowed only one reschedule, and only one-lifetime visit. We do not allow clients to pick out their furniture. Please ensure each client you refer is aware of this. Our inventory is completely reliant on community donations. There are times when we just do not have the requested items at the time of a referral. We review our waitlist and inventory daily to serve as many clients as quickly as possible. Any special requests for style or size of furniture will extend the wait time while we wait for donations that match these requests.
Submit Client Referral