Schedule a ORGANIZATION appointment Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Date MM DD YYYY Are you in a Organization? * YES NO Name Organaztion * what organzation you work with? First Name Last Name Financial Stability * I am able to cover all my essential expenses (e.g., rent, utilities, food) without difficulty. Strongly Disagree Disagree Neutral Agree Strongly Agree I do not have the financial resources to purchase the furniture I need at this time. Strongly Disagree Disagree Neutral Agree Strongly Agree Health and Well-being * Please describe your overall health and well-being over the past 12 months. Strongly Disagree Disagree Neutral Agree Strongly Agree Lack of furniture has negatively impacted my daily life, comfort, or health. Strongly Disagree Disagree Neutral Agree Strongly Agree Employment and Economic Opportunities * How has the past year been regarding employment and economic opportunities? Strongly Disagree Disagree Neutral Agree Strongly Agree Lack of furniture has negatively impacted my daily life, comfort, or health. Strongly Disagree Disagree Neutral Agree Strongly Agree Access to Resources and Assistance * Over the past 12 months, did you have access to resources and assistance? Strongly Disagree Disagree Neutral Agree Strongly Agree Receiving furniture assistance would help me create a more stable and secure home environment. Strongly Disagree Disagree Neutral Agree Strongly Agree Housing and Living Conditions * Over the past 12 months, how would you describe your Housing and Living Conditions? Strongly Disagree Disagree Neutral Agree Strongly Agree I am currently in urgent need of furniture assistance to improve my living conditions. Strongly Disagree Disagree Neutral Agree Strongly Agree Community and Social Support * In the past 12 months, how would you describe your community and social support? Strongly Disagree Disagree Neutral Agree Strongly Agree I am aware that I may need to arrange transportation or delivery for the furniture provided. Strongly Disagree Disagree Neutral Agree Strongly Agree Final Thoughts * What are your final thoughts on why you need furniture assistance? Strongly Disagree Disagree Neutral Agree Strongly Agree I would recommend this furniture assistance program to others in need. Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you for submitting your form. We appreciate your promptness and interest in our services at DGS FURNITURE. Your information has been received and will be reviewed by our team.If you have any further questions or need assistance, please do not hesitate to reach out.Best regards,
