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Operation Furnish Referral Form
REFERRAL CONTACT INFORMATION
Case Manager Name
*
First Name
Last Name
Case Manager Organization/Employer
*
Case Manager Email
*
Verify Email
*
Referral Type:
*
NC Serves Referral
VOA
HUD/VASH Social Worker
Other
If other, please specify.
VETERAN CONTACT INFORMATION
Name
*
First Name
Last Name
Email
Verify Email
Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
County of residence
*
VETERAN INFORMATION
Select all that apply
*
Transition (becoming self-reliant after a job loss, homelessness, abuse, addiction, etc.)
Disaster Relief (immediate need as a result of fire, tornado, flood, hurricane, etc.)
Other*
*If other, please specify:
Military Service Verification
DD214 or Military ID
DEMOGRAPHIC INFORMATION
Used for reporting purposes only.
Age range
*
18-21
22-30
31-40
41-50
51-60
60+
Prefer not to say
Era(s) of service
*
Select all that apply
Pre-Korean (1947-1950)
Korean War (1950-1955)
Post-Korean War (1955-1961)
Vietnam Era (1961-1975)
Post-Vietnam (1975-1990)
Persian Gulf War (1990-2001)
Post 9-11 (on or after 9/11/2001)
Prefer not to say
Gender
*
Female
Male
Non-binary
Other
Prefer not to say
Race/ethnicity
*
African American or Black
Asian
Hispanic or Latinx
Native American or Pacific Islander
Multi-Racial
White
Prefer not to say
DESCRIPTION OF HOME
Has the client moved into their residence officially?
*
Yes
No
Size of the home/apartment (number of bedrooms)
*
What floor?
*
Total number of persons living in the home?
*
Current home furnishing needs:
*
Select all that apply
Bed Frame
Mattress
Bedding (comforter, sheets, pillows)
Dresser
Nightstand
Table Lamp
Couch / Loveseat (depending on availability)
Recliner or Chair (depending on availability)
Coffee table
Side table
Kitchen table
2 Kitchen table chairs
4 Kitchen table chairs
2 Barstools
Dishes Box (dishes, flatware, glasses, and mugs)
Cooking Box (pots, pans, cooking utensils)
Bathroom Box (towels, shower curtain, shower rod)
Desk
Desk chair
Referring Case Manager Check List
Has explained to the client its a once-in-a-lifetime opportunity to receive furnishings from The Joel Fund.
*
Yes
Has notified the client that household furnishings are gently used and have been donated.
*
Yes
Has notified the client that items cannot be exchanged and come "as is", free of charge.
*
Yes
Acknowledges a referral can only be submitted once a client has moved into their place.
*
Yes
