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, LLCA Simple Therapy LLCAcadia HealthcareAcceleration ChurchACCESS-Maine Behavioral HealthcareAction for LifeAllen Avenue UUAlliance Case ManagementAllied Community ServicesAlternative Services of NortheastAlternative Wellness ServicesAmedisys Home CareAmistadAndroscoggin Home Care, Martins Point Community Care TeamAngleZ Behavioral Health ServicesAngolan Community of MaineAscentria Care AllianceASPIREAvesta HousingBarry AtwoodBaySide NeuroRehabilitation Services-GINNEBeacon Health Community Care TeamBet Ha'am CongregationBethel Christian CenterBible Society of MaineBig Brothers Big Sisters of Southern MaineBio-One MaineBrain Injury Services of GoodwillBridges to ChangeBright Future Healthier YouCadence Cove Mgmt.Caleb GroupCanal SchoolCape Elizabeth Lions ClubCaring UnlimitedCasco Bay Community SupportCasco Bay Rescue MissionCathedral Church of St. LukesCatholic CharitiesCentral Maine Counseling Key 3 WestChild Development ServicesChristchurch Evangelical CovenantChurch of Jesus Christ of Latter-Day SaintsCignaCity of Portland Community Health CenterCity of Portland Family ShelterCity of Portland General AssistanceCity of Portland Homeless ShelterCity of Portland Police DepartmentCity of Portland Public HealthCity of Portland Refugee and Immigrant ServicesCity of Portland Social ServicesCity of Portland Office of Elder AffairsCity of South Portland General AssistanceCity of Westbrook Community ServicesCity of Westbrook General AssistanceCLIPCOCOMAINEColor of CommunityCommon Ties Mental Health ServicesCommunity Counseling ServicesCommunity Financial LiteracyCommunity Housing of MaineCommunity Recovery Liaison ProgramCommunity Support ServicesCongolese Community of MaineConnections for KidsCOR HealthCounseling Services, Inc. WestbrookCreative Work SystemsCrisis and Counseling CentersCultivating CommunityCumberland County Homelessness PreventionDay OneDisciple International ChurchDeering Center Community ChurchDeering High SchoolDepartment of Health and Human ServicesDepartment of Veterans AffairsDHSDirect Community CareDirigo Counseling Clinic. LLCDiscovery HouseEast Point Christian ChurchEaster SealsEIM/Seniors PlusElder Service ConnectionsElder's Independence of MaineEnso Recovery ServicesFacing ChangeFaithful International Church of GodFalmouth Food PantryFamily CrisisFamily Friend/InterpreterFamily MedicineFamily ShelterFedcap Rehabilitation Services, Inc.First Parish UU ChurchFirst PlaceFlorence HouseFrannie Peabody CenterFurniture FriendsGateway Community ServiceGBSGod's Peace AssemblyGoodwill IndustriesGrace Street MinistryGraham Behavior ServicesGreater Portland Family PromiseGreater Portland HealthGroup Main StreamGroups Recovery TogetherHand of MercyHealth Affiliates MaineHealth Care Resource CentersHealthy Healing CounselingHelping HandsHome to StayHope ActsHope For All Community Services LLCHope GatewayHopeful LinksHospice of Southern MaineHUD Housing & Community Housing of Maine (CHOM)Humana at HomeHusky Hunger InitiativeHuston CommonsImmigrants Support AssociationILAP (Immigrant Legal Advocacy Project)In Her PresenceIndependence AssociationIndependence NorthwestInterpert MaineJewish Family ServicesKidsPeaceKindred SpiritsLadder to the Moon NetworkLDS Relief SocietyLearningWorksLifeline for MELight Mission ChurchLighthouse Christian MinistriesLiving InnovationsLong Creek Youth Development CenterLoring House AptsMaine Access Immigrant NetworkMaine Association for New Americans (MANA)Maine Behavioral HealthcareMaine Bureau of Veterans' ServicesMaine DHHSMaine Equal JusticeMaine Families York CountyMaineHealthMaine Healthcare At HomeMaine Immigrant and Refugee ServicesMaine Immigrants Rights CoalitionMaine InitiativesMaine Inside OutMaine Medical CenterMaine Medical PartnersMaine NeedsMaine Pretrial ServicesMaine Vocational and Rehabilitation AssociatesMaine WorksMano en ManoMartin's Point Health CareMAS Community HealthMAS Home Care of MaineMassachusetts Care Coordination Network (Mystic Valley Elder Services site)MBH access programMcAuley ResidenceMercy HospitalMerrimack River Medical ServicesMerrymeeting Behavioral Health AssociatesMichael Klahr Jewish Family ServicesMidcoast Maine Community Action Head StartMid Coast Behavioral Health Outpatient ServicesMilestone RecoveryMilestones Family ServicesMind Body Therapy MaineMobile Senior Counseling ServicesMorrison CenterMaine Vocational Rehab. AssociatesMy Sister's KeeperNew England Arab American OrganizationNew England RehabilitationNew Mainers Assistance ProgramNew Mainers Tenants' AssociationNFI NorthNorth Deering Alliance ChurchNorthern Light Home HealthNorthfield Green ApartmentsOpportunity AllianceOpportunity Alliance Maine FamiliesOxford House Inc.Oxford Street ShelterPark Avenue Church of GodPathwaysPeabody CenterPersonal ReferencePharos House Halfway HousePhiladelphia Church PortlandPine Tree Community ServicePine Tree SocietyPortland Adult EducationPortland Career CenterPortland Community Health CenterPortland Help CenterPortland High SchoolPortland Housing AuthorityPortland Mentoring AlliancePortland Police DepartmentPortland Public SchoolsPortland Public Schools Multilingual/Multicultural CenterPortland Recovery Community CenterPortland Refugee Center/Health Affiliates MainePortland Vet CenterPort ResourcesPreble Street Anti-Trafficking ServicesPreble Street Learning CollaborativePreble Street - Logan PlacePreble Street ShelterPreble Street Rapid RehousingPresente! MainePreservation ManagementProbation DepartmentProject for Supported Living (PSL) Services StriveProject GRACEProsperityMEProvidence Human SerivesPSL Services (Project for Supported Living)RE/MAX HeritageResident Services CoordinatorResidential and Community Support ServicesRoot CellarRSU #57Saco Falls ManagementSacred Heart - St. DominicsSalvation ArmySawyer Street Group Home, Volunteers of America NNESeaside Family HealthcareSeaside RehabSecond Parish Orthodox Pres. ChurchSeeds of HopeSelfSeniors PlusSequel Care of MaineShalom HouseSherwood Properties, LLCSMART Child and Family ServicesSomali Bantu Youth Association Of MaineSouth Portland High SchoolSouth Portland Housing AuthoritySouth Portland SchoolsSouthern Maine Agency on AgingSouthern Maine DialysisSpurwinkSt. Andre The Center for Parenting and PlaySt. Anthony of Padua Catholic ChurchSt. Elizabeth'sSt. Lukes CathedralSt. Mary's Episcopal ChurchState Street ChurchState Street PreservationStepping StonesStrive HealthSudanese Community of MaineSupporting Immigrant TenantsSweetserTeen CenterTerry Garmey & AssociatesThe Church of the Holy SpiritThe First Parish Unitarian UniversalistThe Integrated LifeThe Progress CenterThe REAL SchoolThrough These DoorsTop of the Hill CounselingTown of Gorham Fire DepartmentTown of Naples General AssistanceTown of Scarborough General AssistanceTransformation ProjectTrinity Jubilee CenterUnited States Attorney's OfficeUnited States Probation and PretrialUSA Family Well BeingUSMVALDAR GRP LLC Sober Living ResidencesVeteran House ServicesVeterans AdministrationVeterans Helping VeteransVeterans Housing ServiceVeterans Student Organization - Southern Maine Community CollegeVineyard Church of Greater PortlandVisiting Nurse Home Health and HospiceVNA Home Health and HospiceVoices from Nations MinistriesVolunteers of AmericaWaban ProjectsWay of Life MissionWayside Food ProgramsWebPTWelcoming the StrangerWellspringWestbrook Community PolicingWestbrook HousingWestbrook PoliceWestbrook Recovery Liaison ProgramWestbrook SchoolsWestSide NeuroRehabWilliston-Immanuel United ChurchWIN - Welcoming Immigrants NetworkWoodfords ChurchWoodfords Family ServicesYarmouth Compassionate Housing InitiativeYCSPI Serenity HouseYMCAOther 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 * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY 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 ElizabethCumberlandFalmouthFreeport (Pickup Only)Gorham (Pickup Only)PortlandScarboroughSouth PortlandWindham (Pickup Only)WestbrookYarmouthOther Client City Client State * ME Client Zip * Your client is outside of our service area. Please select where they are moving from. * Anchor Inn in South PortlandBudget Inn in South PortlandBest Western in FreeportComfort Inn in SacoComfort Inn in South PortlandDays Inn in South PortlandExpoHoward Johnson in South PortlandMaine Motel in South PortlandMotel 6 in PortlandPine Haven Motel in South PortlandShelterNone 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 LowLowLow ModerateModerate (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 * WhiteAmerican Indian/Alaskan NativeAsianBlack/African-AmericanNative Hawaiian/Other Pacific Islander Can adults speak English? * Yes, very well Yes, a little No, beginner Language(s) Other Than English Spoken * -English Only-ArabicDariDioulaFrenchGermanHindiItalianKikongoKinyarwandaKirundiKiswahiliLaoLingalaMoorePortuguesePunjabiRussianSomaliSpanishSwahiliTshilubaOther 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.