Furniture Referral Form Refer A Client Admin Section Agency Information I have read and understand the conditions stated above. * I have read and understand the conditions stated above. Organization Name * 481 Danforth St, LLC A Simple Therapy LLC Acadia Healthcare Acceleration Church ACCESS-Maine Behavioral Healthcare Action for Life Allen Avenue UU Alliance Case Management Allied Community Services Alternative Services of Northeast Alternative Wellness Services Amedisys Home Care Amistad Androscoggin Home Care, Martins Point Community Care Team AngleZ Behavioral Health Services Angolan Community of Maine Ascentria Care Alliance ASPIRE Avesta Housing Barry Atwood BaySide NeuroRehabilitation Services-GINNE Beacon Health Community Care Team Bet Ha'am Congregation Bethel Christian Center Bible Society of Maine Big Brothers Big Sisters of Southern Maine Bio-One Maine Brain Injury Services of Goodwill Bridges to Change Bright Future Healthier You Cadence Cove Mgmt. Caleb Group Canal School Cape Elizabeth Lions Club Caring Unlimited Casco Bay Community Support Casco Bay Rescue Mission Cathedral Church of St. Lukes Catholic Charities Central Maine Counseling Key 3 West Child Development Services Christchurch Evangelical Covenant Church of Jesus Christ of Latter-Day Saints Cigna City of Portland Community Health Center City of Portland Family Shelter City of Portland General Assistance City of Portland Homeless Shelter City of Portland Police Department City of Portland Public Health City of Portland Refugee and Immigrant Services City of Portland Social Services City of Portland Office of Elder Affairs City of South Portland General Assistance City of Westbrook Community Services City of Westbrook General Assistance CLIP COCOMAINE Color of Community Common Ties Mental Health Services Community Counseling Services Community Financial Literacy Community Housing of Maine Community Recovery Liaison Program Community Support Services Congolese Community of Maine Connections for Kids COR Health Counseling Services, Inc. Westbrook Creative Work Systems Crisis and Counseling Centers Cultivating Community Cumberland County Homelessness Prevention Day One Disciple International Church Deering Center Community Church Deering High School Department of Health and Human Services Department of Veterans Affairs DHS Direct Community Care Dirigo Counseling Clinic. LLC Discovery House East Point Christian Church Easter Seals EIM/Seniors Plus Elder Service Connections Elder's Independence of Maine Enso Recovery Services Facing Change Faithful International Church of God Falmouth Food Pantry Family Crisis Family Friend/Interpreter Family Medicine Family Shelter Fedcap Rehabilitation Services, Inc. First Parish UU Church First Place Florence House Frannie Peabody Center Furniture Friends Gateway Community Service GBS God's Peace Assembly Goodwill Industries Grace Street Ministry Graham Behavior Services Greater Portland Family Promise Greater Portland Health Group Main Stream Groups Recovery Together Hand of Mercy Health Affiliates Maine Health Care Resource Centers Healthy Healing Counseling Helping Hands Home to Stay Hope Acts Hope For All Community Services LLC Hope Gateway Hopeful Links Hospice of Southern Maine HUD Housing & Community Housing of Maine (CHOM) Humana at Home Husky Hunger Initiative Huston Commons Immigrants Support Association ILAP (Immigrant Legal Advocacy Project) In Her Presence Independence Association Independence Northwest Interpert Maine Jewish Family Services KidsPeace Kindred Spirits Ladder to the Moon Network LDS Relief Society LearningWorks Lifeline for ME Light Mission Church Lighthouse Christian Ministries Living Innovations Long Creek Youth Development Center Loring House Apts Maine Access Immigrant Network Maine Association for New Americans (MANA) Maine Behavioral Healthcare Maine Bureau of Veterans' Services Maine DHHS Maine Equal Justice Maine Families York County MaineHealth Maine Healthcare At Home Maine Immigrant and Refugee Services Maine Immigrants Rights Coalition Maine Initiatives Maine Inside Out Maine Medical Center Maine Medical Partners Maine Needs Maine Pretrial Services Maine Vocational and Rehabilitation Associates Maine Works Mano en Mano Martin's Point Health Care MAS Community Health MAS Home Care of Maine Massachusetts Care Coordination Network (Mystic Valley Elder Services site) MBH access program McAuley Residence Mercy Hospital Merrimack River Medical Services Merrymeeting Behavioral Health Associates Michael Klahr Jewish Family Services Midcoast Maine Community Action Head Start Mid Coast Behavioral Health Outpatient Services Milestone Recovery Milestones Family Services Mind Body Therapy Maine Mobile Senior Counseling Services Morrison Center Maine Vocational Rehab. Associates My Sister's Keeper New England Arab American Organization New England Rehabilitation New Mainers Assistance Program New Mainers Tenants' Association NFI North North Deering Alliance Church Northern Light Home Health Northfield Green Apartments Opportunity Alliance Opportunity Alliance Maine Families Oxford House Inc. Oxford Street Shelter Park Avenue Church of God Pathways Peabody Center Personal Reference Pharos House Halfway House Philadelphia Church Portland Pine Tree Community Service Pine Tree Society Portland Adult Education Portland Career Center Portland Community Health Center Portland Help Center Portland High School Portland Housing Authority Portland Mentoring Alliance Portland Police Department Portland Public Schools Portland Public Schools Multilingual/Multicultural Center Portland Recovery Community Center Portland Refugee Center/Health Affiliates Maine Portland Vet Center Port Resources Preble Street Anti-Trafficking Services Preble Street Learning Collaborative Preble Street - Logan Place Preble Street Shelter Preble Street Rapid Rehousing Presente! Maine Preservation Management Probation Department Project for Supported Living (PSL) Services Strive Project GRACE ProsperityME Providence Human Serives PSL Services (Project for Supported Living) RE/MAX Heritage Resident Services Coordinator Residential and Community Support Services Root Cellar RSU #57 Saco Falls Management Sacred Heart - St. Dominics Salvation Army Sawyer Street Group Home, Volunteers of America NNE Seaside Family Healthcare Seaside Rehab Second Parish Orthodox Pres. Church Seeds of Hope Self Seniors Plus Sequel Care of Maine Shalom House Sherwood Properties, LLC SMART Child and Family Services Somali Bantu Youth Association Of Maine South Portland High School South Portland Housing Authority South Portland Schools Southern Maine Agency on Aging Southern Maine Dialysis Spurwink St. Andre The Center for Parenting and Play St. Anthony of Padua Catholic Church St. Elizabeth's St. Lukes Cathedral St. Mary's Episcopal Church State Street Church State Street Preservation Stepping Stones Strive Health Sudanese Community of Maine Supporting Immigrant Tenants Sweetser Teen Center Terry Garmey & Associates The Church of the Holy Spirit The First Parish Unitarian Universalist The Integrated Life The Progress Center The REAL School Through These Doors Top of the Hill Counseling Town of Gorham Fire Department Town of Naples General Assistance Town of Scarborough General Assistance Transformation Project Trinity Jubilee Center United States Attorney's Office United States Probation and Pretrial USA Family Well Being USM VALDAR GRP LLC Sober Living Residences Veteran House Services Veterans Administration Veterans Helping Veterans Veterans Housing Service Veterans Student Organization - Southern Maine Community College Vineyard Church of Greater Portland Visiting Nurse Home Health and Hospice VNA Home Health and Hospice Voices from Nations Ministries Volunteers of America Waban Projects Way of Life Mission Wayside Food Programs WebPT Welcoming the Stranger Wellspring Westbrook Community Policing Westbrook Housing Westbrook Police Westbrook Recovery Liaison Program Westbrook Schools WestSide NeuroRehab Williston-Immanuel United Church WIN - Welcoming Immigrants Network Woodfords Church Woodfords Family Services Yarmouth Compassionate Housing Initiative YCSPI Serenity House YMCA Other Organization Name Look through the list carefully before choosing Other. Type in the search box to find matches. Please contact us at firstname.lastname@example.org to have your agency/organization added to our list of referrers. Please include the complete name of the organization and the primary contact person. Agency Contact First Name * Agency Contact Last Name * Agency Address * Agency Address Line 2 Agency City * Agency State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Agency Zip * Phone * Extension May we text this number? * Yes No Agency Email * Preferred Contact * Phone Email Text Case manager/client able to pick item(s) up? * Case Mgr. Pick Up Client Pick Up Unable, please deliver curbside By selecting curbside delivery, you or your client agrees to be responsible for transporting the furniture from the curb/truck into their apartment upon delivery. Client Information Client First Name * Client Last Name * United States Veteran? * Yes No Is this veteran a participant of the 100 Veterans Challenge? Yes No Client Address * Client Address Line 2 Client City * Cape Elizabeth Cumberland Falmouth Freeport (Pickup Only) Gorham (Pickup Only) Portland Scarborough South Portland Windham (Pickup Only) Westbrook Yarmouth Other Client City Client State * ME Client Zip * Your client is outside of our service area. Please select the hotel they are moving from. * Anchor Inn in South Portland Budget Inn in South Portland Best Western in Freeport Comfort Inn in Saco Comfort Inn in South Portland Days Inn in South Portland Howard Johnson in South Portland Maine Motel in South Portland Motel 6 in Portland Pine Haven Motel in South Portland None INVALID CITY SELECTION: Please select a city within our service area listed above. Your client is outside of our delivery area and will need to arrange to pick up the furniture from our warehouse. Please ensure that you have selected either Case Mgr. Pickup or Client Pickup above. INVALID CITY SELECTION: Please select a city within our service area listed above. NOTE: As part of the 100 Veterans Challenge, your client is located outside of our delivery area and will need to arrange to pick up the furniture from our warehouse. Please ensure that you have selected either Case Mgr. Pickup or Client Pickup above. NOTE: As part of the Catholic Charities Afghan Resettlement Program, your client is outside of our delivery area and will need to arrange to pick up the furniture from our warehouse. Please ensure that you have selected either Case Mgr. Pickup or Client Pickup above. NOTE: As part of the Jewish Community Alliance Afghan Resettlement Program, your client is outside of our delivery area and will need to arrange to pick up the furniture from our warehouse. Please ensure that you have selected either Case Mgr. Pickup or Client Pickup above. Client Phone * Does client text? * Yes No Client Email Number in Household * Female(s) * Male(s) * Genderqueer/Non-Binary * Under Age 18 * Income Level * Extremely Low Low Low Moderate Moderate (xxxxxxxxxx) Country of Origin * Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (DRC) Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (North Korea) Korea (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Ethnicity * Hispanic or Latino Not Hispanic or Latino Race * White American Indian/Alaskan Native Asian Black/African-American Native Hawaiian/Other Pacific Islander Can adults speak English? * Yes, very well Yes, a little No, beginner Language(s) Other Than English Spoken * -English Only- Arabic Dari Dioula French German Hindi Italian Kikongo Kinyarwanda Kirundi Kiswahili Lao Lingala Moore Portuguese Punjabi Russian Somali Spanish Swahili Tshiluba Other Select as many as appropriate Do any family members have special needs? * Yes No Special Needs Description * Furniture Requested Furniture Friends only provides furniture in the categories listed below. If it is not listed below, we do not provide it. Column 1 Loveseat(s) Full Size Couch(es) Lounge Chair(s) Coffee Table(s) Column 2 Dining Table(s) Dining Chair(s) Column 3 Bookshelves Area Rug(s) Desk(s) Desk Chair(s) Lamp(s) Bedrooms Column 1 Twin Boxspring(s) Twin Mattress(es) Double Boxsprings(s) Double Mattress(es) Queen Boxspring(s) Queen Mattress(es) Portable Crib(s) Bedrooms Column 2 Bedrooms Column 3 Bedside/End Table(s) Dresser(s) Case Manager Notes CAPTCHA If you are human, leave this field blank.