Furniture Share Form

Furniture Share Request Form

Welcome to the Furniture Share request form! Please take a moment to fill out the following information on behalf of your client. Accurate details will help us process the request efficiently and ensure that we provide the necessary furniture and services.

Full Name:

Date of Birth:

Phone Number:

Email:

Household Location

Address:

City:

State:

Zip:

County:

Household Composition

Adults in Household:

Children in Household:

Income Range:

Extremely Low Income (less than or equal to 30% AMI)
Very Low Income (30-50% AMI)
Low Income (50-80% AMI
Not Low Income (greater than 80% AMI)

OHP/IHN Eligible?

ID number:

Medicaid Eligible?

Household Situation (indicate number of individuals for each category)

Disable Adults:
Disabled Children:
Homeless:
Alcohol/Drug:
Elderly/Frail:
Domestic Violence:
Homelessness Risk:
Mental Illness:
Developmentally Disabled:
Fire Displacement:
Veteran:

Race/Ethnicity (indicate number of individuals for each category)

White:
Black or African American:
Hispanic or Latino:
Asian:
American Indian or Alaska Native:
Native Hawaiian or Other Pacific Islander:
Other:

Service Fee:

Bill to:

Caseworker
Client

List of items you are requesting:

After completing the section above, please email it to Yesenia at hola@communitydoulaprogram.org. If you have any questions, you can also call or text Monday through Friday, 9 am to 5 pm, at (541) 220-5653.

Important notes:

Fees: Each household accessing service is subject to a fee payable at the time of your furniture pickup or delivery.
Food box requests: Please submit your request before Wednesday. Orders placed before Wednesday will be available for pick-up the following Friday after 10:30 am at Monarch on 4th. Example: If I submitted my order on Wednesday 9/4 by order would be ready to pick up on 9/13.
Furniture requests: Furniture Share will contact your client directly when the requested items are available. They will provide options for pick-up or delivery. You can choose the furniture you would like but not the color or style.
Bed requests: Please note that you cannot choose the type of bed or when it will be available. Occasionally, beds may be out of stock, and clients will need to wait until they become available. While we strive to meet all requests, availability is dependent on our current inventory.
Delivery cancellation policy:Scheduled deliveries must be rescheduled at least two business days in advance. Failure to do so may result in the client being marked as “served.” Missed delivery appointments will still require payment for the initial delivery, and rescheduling will require upfront payment. Missed pickup appointments will be canceled.

Furniture share guarantee to provide each client with the following high needs items: