Online Referral Form

This form MUST be completed fully by the referral agent and NOT by the client. The referral agent must provide two telephone contact numbers for the client at the time of completing the referral request (it is not acceptable for the Referral agent to be the second contact number other than in exceptional circumstances)

Please note: Roundabout is no longer providing furniture via referrals to persons resident within the Worcester City boundary.

Furniture referrals for Worcester City residents should now be made to Armchair 01905 456080

Please read the Referral Terms before filling in the form. You will be required to agree to these terms before the information can be submitted.

Should you require an item not on the list then please contact the office before submitting the form and enter the details discussed in the ‘Other Information’ box below.

Please fill in the details in the boxes or select, as required.  An asterisk denotes a required field. When completed, please click the send button. If there are any omitted required fields, you will be prompted to fill them in before clicking the send button again. Once successful, a confirmation will display on screen and an email will be sent to the Roundabout office.
Please ensure all details are entered correctly.

Covid-19 Government guidelines may result in the clients furniture only being delivered to the roadside door of the clients address.

The Referral Form has been updated, as of May 2019, to include a mandatory alternative contact number. This is to minimise the risk of non-delivery due to the primary contact numbers not being answered. A referral request will not be processed unless an alternative contact number is provided which should not be the referral agent (unless there are exceptional circumstances)

    Referral Agency and Client Details

    Referral Agency Client
    Your ref.
    e.g. Order No.
    Agency* Name*


    Town* Town*
    County* County*
    Postcode* Postcode
    (reqd. if known)
    Referral Agent Phone
    (reqd. if known) Alternative Contact Number* (mandatory)
    Name* Mobile
    (reqd. if known)
    Dept. Email
    Phone* Notes
    (reqd. if available)


    Miscellaneous Data (Questions in italics are for statistical purposes and purely voluntary)

    Who is to pay the charges?*   
    Age of Client (select one):   16-2526-5051-6465+Prefer Not To Say
    Client Status (select one)  SingleSingle ParentMarried/Co-habiting CoupleOtherPrefer Not To Say
    If other please specify  
    No. of Children:  0-3 years   4-10 years   11-15 years
    Type of Premises* (select one)  HouseGround Floor FlatUpstairs FlatBungalowBedsitCaravan
    Housing Association Name  


    Furniture Required

    Please remember to take into account stair access and room size when requesting larger items such as wardrobes and settees.

    Item £ Qty Item £ Qty Item £ Qty
    Double Bed Base £9 Cot
    (if possible will include mattress)
    £5 Desk    (Select type)
    Double Bedding £7 Recliner Chair (electric) £15 Rug  (Specify size below) £4
    Double Headboard £1 Settee (3 seater) £20 Dining Table £14
    Double Mattress £9 Settee (2 Seater) £18 Dining Chair (each) £3
    Single Bed Base £7 Armchair
    (if possible will match)
    £8 Kitchen Table £10
    Single Bedding £6 Fireside Chair (upright)
    (Specify size below)
    £7 Kitchen Chair (each) £3
    Single Headboard £1 Recliner Chair (manual £8 Kitchen Starter Pack £10
    Single Mattress £7 Sideboard £5 Ironing Board £3
    Bunk Bed (2 Tier)
    (Order mattresses separately)
    £18 Wall Unit £7
    Curtains £2 per pair
    Qty WINDOW Width
    (State cm or ins)
    WINDOW Height
    (State cm or ins)
    Chest of Drawers £7 Bookcase £5
    Wardrobe (Select size)
    £10 Occasional Table £4
    Bedside Cabinet £4 TV Cabinet/Stand £4
    Dressing Table £3 CD Storage Unit £1
    Other Information:
    (i.e. Additional Items and Special requirements; e.g. Rug size(s); Fireside Chair Height to Seat & Depth)


    In the box below, please enter the numbers and/or letters in the box above in the same order as you see them

    Tick to confirm you have read and accept our Referral Terms   

    Click this button to send the data as an email
    (this is only possible after acceptance of our terms)      

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    Opening Hours: Monday - Thursday 9am - 1pm (except bank holidays)   First Saturday 10am - 2pm  Tel: 01386 83 30 30