Client Referral Form

Off the Floor Pittsburgh

901 Allegheny Avenue - Pittsburgh, PA 15233

412-926-5053 | Email: donations@offthefloorpgh.org

Enter Agency Info

Date of Referral(Required)

Agency Name(Required)

Caseworker(Required)

Email(Required)

Caseworker Phone Number(Required)

Phone(Required)

Type of Service Requested
(Agency Must Select One Option)

Type of Service Requested(Required)

Enter Client Info

Client Name(Required)

Primary Phone Number(Required)

Alternate Phone Number

Street Address(Required)

Apartment Number

Address(Required)

Is the client currently in residence(Required)

Move in date(Required)

Marital Status(Required)

Annual Household Income(Required)

Ethnicity(Required)

Number of Children in the Household
(Please List Gender And Ages)

Number of Children in the Household (Please List Gender And Ages)

Gender

Age

Number of Adults in the Household
(Please List Gender And Ages)

Number of Children in the Household (Please List Gender And Ages)(Required)

Gender

Age

Details about residence

Primary reason why furniture is needed (check all that apply)(Required)

Explain reason why furniture is needed(Required)

List Furniture items needed(Required)

Comments

Caseworkers Please Note

We provide basic furniture items such as sofas/loveseats, end tables, living room chairs/recliners, bookcases, dining tables/chairs, beds and dressers.
We cannot provide small or large appliances, pots/pans, dishes, bathroom items, curtains or clothing.

Thank you for your life-changing donation.

When you donate to Off the Floor, you help give families the opportunity to create a comfortable living space where they can feel safe and welcome. Your generosity will help to strengthen families and create communities where we all belong!

Enter Agency Info

Enter Client Info

Caseworkers Please Note

Off the Floor

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Thank you for your life-changing donation.