• Client Referral Request

    **This form can only be completed by a verified Social Worker and a qualified referring Agency.

  • Please Read:

    **At this time we are only able to deliver to addresses that are within a 20 mile radius of the warehouse, which is located at 400 Roberts Road, Oldsmar, FL 34677. **We are only able to help a select number of families per month, based on available donations and resources.  Priorities are given to families who have nothing and families who are sleeping on the floor or caring for foster children. Please provide as much information as possible about your client and their situation.

  • Notice:

    Please do not complete an application if the client is not currently living in their home, or their move-in date is more than two weeks in the future. Part of our screening process requires the client to send pictures of their living space so we can properly assess their needs. If they aren't in the home yet we can't complete our screening process.

  • Social Worker Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Client Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Situation that is causing your client to need assistance from New Life Warehouse:

  • Was your client homeless within the last two months?*
  • Choose the most recent event that contributed to their need for furniture and household supplies:*
  • Which current situation best describes what has caused your client to need furniture and household goods:*
  • Which situation best describes what has caused your client to need furniture?
  • What language does the client speak?*
  • Are there children living in the home?*
  • Rows
  • Are there other adults living in the home?*
  • Rows
  • Which option best describes your client's furniture situation?*
  • Does the family currently live in the house or apartment?*
  • Move-in Date or expected move-in date for new residence. *
     - -
  • How is the family paying for their rent?*
  • New Life Warehouse will only serve a family one time. We don't want to deliver furniture to a family who will be unable to stay in their current residence. Knowing that, is this the proper time for them to receive furniture?*

  • Final Internal Process Details - Please read through the following statements and confirm that you understand what happens once your referral is submitted.

  • Why is the client not capable of completing the application?*
  • Should be Empty: