Furniture Ministry Referral | First Presbyterian Church

Furniture Ministry Referral Form

Client Name

Client Phone Number *

Number of Adults

Number of Children

Ages & Sex of Children

Pajama Sizes for Children (An agency provides pajamas for children up to 18 years of age; please specify if Child or Adult size)

Address

City

State

Zip

Name of Apartment Complex or Neighborhood

Apartment Level Floor

Number of Bedrooms

Upstairs or Ground Floor

Items Requested

All furniture and household requests are based on availability. Children under 18 will always receive a twin bed only.

Adult Queen Or Full mattress & box spring and frame

How many requested?

Child Reg twin Or Twin XL mattress and box spring and frame (under 18 years of age gets bed)

How many requested?

Dining Table/chairs (Limit of 4 chairs per family)

How many chairs requested?

Chest/Dresser (Limit 1 per family)

Linens

What linens are needed?

Sofa OR Loveseat

Preference

Upholstered Chair

How many requested?

Coffee Table OR End Table

Preference

Lamps

How many requested?

Other

Please list:

Any special needs to consider?

Client Resides in Alamance County

Yes

Has there been a home visit by referring agency?

Yes

Does the client have access to a truck to pick up their furniture?

Yes

Reason for Referral: (Please attach verification of need if available)

Moving from homelessness (letter from shelter, mental health agency or parole officer)

Domestic violence (letter from shelter or police report or family abuse services)

Recovering from fire/flood/crisis (letter from Red Cross, Insurance Report, or Fire Department report)

Income does not meet basic needs (Pay stubs, SSI letter or public assistance letter)

Bed Bugs – Attach letter verifying date and type of treatment (required)

Referral Agency

Referral Person/Title

Referral Person Phone

Referral Person Email

I have filled this out with the information provided by the client. Typing my name here serves as my signature.

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Furniture Ministry Referral Form

Items Requested

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