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DCH Referral Form

Instructions:

In addition to the form below, a letter from the shelter, transitional housing program, or other social service agency (on official letterhead) confirming the need for furniture must be sent via fax to 774-243-3871 or email to dch@cmhaonline.org

Client Information

Client Name (Head of Household)

Preferred Language

Last 4 of SSN

Client Phone Number

Client Email

Referring Agency Info

Agency Name

Agency Phone Number

Case Manager Name

Case Manager Email

Helpful Links

DCH Referral Form (pdf)
DCH Pickup Schedule
Additional furniture resources in the area