OT Home Safety and Accessibiity Assessment Pricing Form
As regulated healthcare professionals we are public trustees of personal health information. Your responses will be kept confidential and serve to help us provide you with customized service information tailored to your needs. Our basic assessment service starts at $350, plus travel fees. Receipts can be submitted to insurance plans for reimbursement if they cover occupational therapy services. Additionally, you can submit as medical expense on your personal tax form. Once we receive your completed form we will provide pricing and next steps information, so you can decide if you would like to proceed.
Information about you:
Your first and last name
Your Email Address
Your Phone Number
Choose option that best represents you:
Person Needing the Service
Family Member, Spouse, or Friend
Other
If Other, please specify:
Information about the person in the home needing this service:
First and last name (leave blank if this is you)
Email Address (leave blank if this is you)
Phone number (to set up appointment)
Address where assessment will take place (to determine travel fees)
Which of the following represent the the current situation for the person needing this assessment: (check all that apply)
Older adult (65 years or older)
Has a progressive health condition
Uses a cane or walker to get around
Uses a wheelchair or scooter to get around
There are mental health concerns
There are memory or judgement concerns
Has fallen and/or there are existing or suspected safety hazards in the home
There are existing or suspected accessibility barriers in the home
Recently discharged home from hospital or will be soon
Considering whether to modify the home or move
Future planning for aging in place (not interested in moving)
Moving into a new home
Planning on building a new home
Pre or post-op planning for surgery
Other situation not listed her
If Other, please specify:
Which describes the type of home to be assessed?
1-storey house (attached or detached)
2 or more storey house (attached or detached)
1 level condo
1 level apartment or assistive living suite
Other?
If Other, please specify:
Which of the following are presenting issues for the person needing this assessment:
Unable, unsafe or having difficulty with stairs
Unable, unsafe or having difficulty bathing, showering or toileting
Unable, unsafe or having difficulty getting in and out of bed
Unable, unsafe or having difficulty with meal preparation and clean up tasks.
Unable, unsafe or having difficulty with laundry and/or housekeeping
Unable, unsafe or having difficulty driving or using other transportation method
Unable, unsafe or having difficulty conducting community outings like grocery shopping or banking
Unable, unsafe or having difficulty getting into/out of the home
Unable, unsafe or having difficulty getting around inside the home
Unable, unsafe or having difficulty getting around outside the home
None of the above, just interested in assessment of the home
Other
If Other, please specify:
Are there current plans for a renovation:
Yes, will share plans at assessment
Yes, I will upload plans here
No current plans, but open to learning about home modifications to increase safety and accessibility
No, not interested in any renovation (don't own home or other reason)
Upload renovation plan or drawings for review prior to assessment
Select a File
Additional Information
Additional Information about the person, the home or current situation that could help us determine the scope of work required for this service
Additional Information about other people in the home (e.g. Another resident in the home with health conditions, disability etc.)
Please list the people who would like to be present at this assessment.
If you decided to proceed with the service, who should we contact to schedule the assessment? If not you, please provide contact info.
I want to join your inclusive community and receive information related to home modifications, accessible housing, and/or aging in place tips and news.
How did you hear about us?
Co-Worker/Friend or Family
Family Doctor
Flyer or Door Hanger
Friend or Family Member
Home & Garden Show (March)
Internet Search
MSOT Private Practice Lisst
Radio Ad or Print Media
Social Media
Home Renovation Show (January)
Other
Submit