Are these modifications for your home or someone else’s?

My Home

My Parent or Grandparent

My Patient or Client

Someone Else

Select the type of residence.

Single-Family Home

Condo

Mobile Home

Other

How can we help modify this home for accessibility?

How can we help modify this home for accessibility?(Stairway, Tub/Shower, Entryway)

Stairway(s)

Tub or Shower

Entryway

How many staircases do you need modified?

Number of Indoor Staircases

Number of Outdoor Staircases

Provide the estimated weight of the primary user.

100-200 pounds

201-300 pounds

301-400 pounds

401-500 pounds

What do you need modified?

What do you need modified?(Tub, Shower, Both)

Tub

Shower

Both

Are you having trouble stepping over your tub?

Yes

No

What kind of tub do you have?

Fiberglass

Cast Iron

Other/I Don’t Know

Would you like grab bars?

Yes

No

I'm Not Sure

Would you like a seat?

No

Yes

I'm Not Sure

What do you need modified?

What do you need modified?(Tub & Shower, Shower Only)

Tub & Shower

Shower Only

Would you like grab bars?

Yes

No

I'm Not Sure

Would you like a seat?

Yes

No

I'm Not Sure

Would you like a detachable/handheld showerhead?

Yes

No

I'm Not Sure

Would you like your shower remodel to have doors?

Yes

No

I'm Not Sure

Where is the home’s primary point of entry?

Front Door

Back Door

Garage

Porch

How can we help modify this home for accessibility?

How can we help modify this home for accessibility(Stairlift, Ramp Platform Lift)?

Stairlift

Ramp

Platform Lift

How many stairs do you have in this entry that we should adjust for?

How soon do you need your modifications made?

As Soon As Possible

Within 2 Weeks

Within 4 Weeks

Within 6 Weeks

No Rush

Let us know how to get in touch with you.

Name*

Phone*

Email*

Zip Code*

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