FM Referral Form

First Presbyterian Church Furniture Ministry

(336) 212-2937, Furnmin3@gmail.com

Client Name

First Last

Client Phone Number

Number of Adults

Number of Children

Ages and 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

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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)

Number of chairs requested?

Chest/Dresser (Limit 1 per family)

How many requested?

Linens

What linens are needed?

Sofa OR Loveseat

How many requested?

Upholstered Chair

How many requested?

Coffee Table OR End Table

How many requested?

Lamps

How many requested?

Other

Please list:

Any special needs to consider?

Please explain

Client Resides in Alamance County

Yes or No

Has there been a home visit by referring agency?

Yes or No

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

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.

FM Referral Form

First Presbyterian Church Furniture Ministry

Items Requested

updated May 2020