REMODEL FOR LIFE, LLC
MN Building Contractor License #BC724661. UMPI #A509145000.
Helping Professionals, we accept all MN DHS Waiver Programs and VA Programs. Please use this form to request an estimate for a Environmental Accessibility Adaptation home modification project. We typically turn-around estimates within 2 weeks of referral receipt.
Requestor's Information
Please provide us with information about yourself
Requestor Name
*
First Name
Last Name
Requestor Email
*
example@example.com
Requestor Phone
*
Please enter a valid phone number.
Requestor Organization
*
County Name, Assessments Service, Etc.
Relationship to Client
Please Select
Parent/Legal Guardian
Case Manager/Social Worker
Occupational Therapist
Doctor
Other
Client Information
Please provide us information about the client
Client Name
*
First Name
Last Name
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone
Please enter a valid phone number.
Client Email (if applicable)
example@example.com
Is there an onsite contact?
*
Please Select
Yes
No
Onsite Contact Name
First Name
Last Name
Onsite Contact Phone Number
Please enter a valid phone number.
Please provide us with a brief description of the project.
Submit
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