Contact Information

Full Name

Email Address

Phone Number

Preferred Contact Method

PhoneEmailEither

Service Needs

Are you looking for home modifications to help a senior remain in their home?

YesNoI'm not sure

What type of modifications or assistance are you looking for? (select all that apply)

Safety modifications (grab bars, ramps, etc.)Accessibility improvements (widening doorways, lowering countertops)General home repairs or maintenanceSmart home technology (security, fall detection, etc.)Other

Who are the modifications for?

MyselfA family memberA friend or neighborOther

How soon do you need the modifications or services?

ImmediatelyWithin the next 1-3 monthsWithin the next 6 monthsI'm not sure

Home Details

Do you currently own or rent the home?

OwnRentOther

What type of home are we assessing?

Single-family homeCondo or apartmentTownhouseOther

How old is the home?

Less than 10 years10-30 years30+ yearsI'm not sure

Additional Information

Please briefly describe any specific concerns or issues you have with the home:

How did you hear about Gramma's House?

Friend or familySocial mediaSearch engineFlyer or advertisementOther

Would you like to schedule a free home assessment?

YesNoMaybe, tell me more

Would you like us to provide references from other homeowners who have used our services?

YesNo