When Somebody Loves You Back Household Item Request Form
Thank you for your interest in working with WSLYB. We provide gently used furniture and household Items. By Completing this form you will be added to our Client Request List. Each client can request up to 3 items. These three items have to be furniture or household items only. Clients may put a request in every six months. WSLYB preferred method for requests would be via caseworker/ social worker. If a client does not have a caseworker or a social worker , they may submit the form and explain at the bottom that they do not have social worker or a case worker. The only method acceptable to receive assistance is via this form. Emails and phone calls will be directed towards this form. We take on 15 clients at a time, when one client on the list is complete we will bump the next client up on the list. Once this happen, you will receive an email and/or a call letting you know that your process has begun. Thank you we look forward to working with you soon.
Name
*
Prefix
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
What are the 3 Items that you would like WSLYB to assist you with?
*
Can you pick up item requested?
*
Yes
No
Meet in office
Do you have any disabilities?
*
How could we assist you?
*
Furniture
Household Item
Referrals
Housing
Other
How did you hear about WSLYB?
*
Facebook
Instagram
County
RCEB
IHSS
Other
Do you have a case worker/ social worker
*
Case Worker Information
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Thank you, we will be in contact!
Submit
Should be Empty: