Furniture Bank Referral Form

Furniture Bank Referral Form

Please complete on behalf of your client. PLEASE DO NOT COMPLETE THIS FORM IF YOU ARE BASED OUTSIDE OF THE UNITED KINGDOM
Client Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Email*
johnsmith@gmail.com
Phone Number*
Please enter a valid phone number.
Address (This refers to the property the furniture items are required for)*

Street Address

Street Address Line 2

Town/CityBorough

Postcode
Employment Status*
Ethnicity *
How did you hear about our services?*
How many adults live in the property? *
This applies to anyone 18 years of age and over
How many children live in the property*
This applies to anyone aged 3 - 17 years of age
How many toddlers / babies live in the property?*
This applies to anyone under 3 years of age
How long has the client lived in the property
How many rooms does the property have?
Furniture items required*
Reason help is required*
Has the client applied to the local authority's Resident Support Scheme for support?*
If 'Yes' when was the application made?
If you don't know the exact date, please provide the month and year the application was made.
What was the outcome of their application?

ApprovedRejectedPending
If 'Approved', how much was/ will be granted?
What items were purchased with the Resident Support Scheme grant?
If 'Rejected' what reason was provided by the local authority for not approving the application?
If 'Pending' when will you be provided with an answer?
Which other grants or loans have been applied for to provide the furniture items required by the client?
Please provide details of any additional support the client is currently receiving. (This can include local authority grants, social services assistance etc)
Does the property require a cleaning service before the furniture is moved in?
This section is about the organisation the client is being referred by
Organisation's Name*
Name of Referrer*
Referrer's Email*
example@example.com
Referrer's Number*
Please enter a valid phone number.
Should be Empty:

Furniture Bank Referral Form

This section is about the organisation the client is being referred by