Assessment for Home Modifications Fill the form to below to give us an idea about your unique situation. With this information we can better understand our aproach for your home modifications. Have you or someone in your household experienced a significant change in mobility, cognition or health status requiring home modifications? Yes - urgent No - not urgent Have you or someone in your household been recently discharged from hospital or will be discharged from hospital and requiring home modifications? Yes - urgent No - not urgent Do you or someone in your household have a progressive medical condition or disability requiring home modifications? Yes - urgent No - not urgent Have you or someone else identified safety hazards in or around your home that could cause a fall or an even worse outcome? Yes - urgent No - not urgent Are you interested in learning about home modifications that can increase participation, independence and safety as you age? Yes No How important is it to you to preserve the esthetics of your home and for this project to not look “institutional” or have a “hospital feel”? 1 (Not important) 2 3 4 5 6 7 8 9 10 (Very important) How important is it to you that you can make informed decisions about home modifications that will benefit you and your household now and into the future so future renovations or a move will not be required as your needs change? 1 (Not important) 2 3 4 5 6 7 8 9 10 (Very important) How important is it to create a home that is “visitable” by your neighbours, friends or family who may have disabilities and require basic accessibility features? 1 (Not important) 2 3 4 5 6 7 8 9 10 (Very important) Name First Last PhoneEmail Research suggests that an assessment by a qualified Occupational Therapist (OT), is recommended prior to engaging in an accessibility construction project. The OT can evaluate the current occupant’s abilities and limitations, identify environmental safety hazards and accessibility barriers, and make recommendations for cost-effective home modifications, assistive devices and accessibility equipment to optimize current and future safety and participation in all daily activities.