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Services
- Home Safety Modification Services
- Companion Care
About Us
Contact Us

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Home
Services
- Home Safety Modification Services
- Companion Care
About Us
Contact Us

Home
Services
- Home Safety Modification Services
- Companion Care
About Us
Contact Us

Tell Us About Your Home – We’ll Handle the Rest

Online Home Safety Assessment Questionnaire

Thank you for considering a Home Safety Modification Assessment. Please complete the following questionnaire to help us understand your needs.

Name

First Last

Phone Number

Email Address

Address

Street Address City ZIP / Postal Code Country

Do you have any pets or animals on the property?

Yes

Who is this assessment for?

Myself

A parent or loved one

A client or patient

Other

Please list the type of pets/animals

[Other]

Safety Awareness

Have you or your loved one had a fall or near-fall in the past 6 months?

Yes

Do you feel unsteady or concerned about falling in certain parts of your home (e.g., bathroom, stairs, entryways)?

Yes

Sometimes

Mobility & Access

Do you currently use a cane, walker, or wheelchair inside your home?

Yes

Are there steps, narrow doorways, or other obstacles that make it difficult to move around your home?

Yes

Not sure

Goals & Concerns

Are you (or your loved one) planning to stay in your home long-term?

Yes, I/we want to age in place

No, I/we’re considering other options

Not sure

What are your biggest concerns about aging at home?

Falls

Bathroom Safety

Stairs

Lighting

Getting in/out of the home

Other

[Other]

Budget Preferences: "Do you have a budget range in mind for home safety modifications?

Less than $1,500

$1,500 - $3,500

$3,500 - $6,500

Over $6,500

Unsure at this time

How did you hear about Home with Ease?

Google

Referral

Social Media

Other

[Other]

Would you like a free consultation to discuss possible home safety solutions?

Yes, please contact me

No, just browsing

Houston, TX USA
info@homewithease.com

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info@homewithease.com

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Weekend: 10am - 4pm

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Home Safety Modification
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Get a Free Estimate Today!

Call us for a cost estimate over the phone

1-555-678-8888

Request an estimate

Call Us Now:

Tell Us About Your Home – We’ll Handle the Rest

Online Home Safety Assessment Questionnaire

Safety Awareness

Mobility & Access

Goals & Concerns

Google map

Opening Times:

Mon - Fri: 9am - 5pm
Weekend: 10am - 4pm

Subscribe Newsletter

Quick Links

Services

Get a Free Estimate Today!

Call us for a cost estimate over the phone

1-555-678-8888

Copyright © 2025 Home with Ease

Terms of Services

Privacy Policy

Call Us Now:

Tell Us About Your Home – We’ll Handle the Rest

Online Home Safety Assessment Questionnaire

Safety Awareness

Mobility & Access

Goals & Concerns

Google map

Opening Times:

Mon - Fri: 9am - 5pm Weekend: 10am - 4pm

Subscribe Newsletter

Quick Links

Services

Get a Free Estimate Today!

Call us for a cost estimate over the phone

1-555-678-8888

Copyright © 2025 Home with Ease

Terms of Services

Privacy Policy

Mon - Fri: 9am - 5pm
Weekend: 10am - 4pm