ABC Consumer Request Form

Architectural Barriers Consultation

ABC Request for Services or Referral
There is a reasonable cost per hour for Homeowners as well as business owners desiring to make their properties more accessible.

After submitting this request form, our Consultant will contact you within a few business days to discuss further details, application, and appointment for the consultation.

At this time services are for Dutchess County residents only.

If you are only interested in community referral information, be sure to select that option.

Each question with a * must be answered.
Date of Request*

MonthDayYear
Date
Please complete the following information for the Barrier-Free Architectural Consultant*

I am the individual/ Homeowner with a disability requesting services.I am a family member requesting services on behalf of the person with the disability.I am an agency/business requesting services on behalf of my client.
The Individual's information collected on this form is to remain confidential unless the individual/consumer signs consent for TRI staff to disclose necessary information to a specific contact.

The Individual must complete an Intake packet to become a Consumer of TRI for services to begin. Otherwise general information and referral will be provided.
Name of the individual with the disability

PrefixConsumer FIRST NAMEMiddle InitialConsumer LAST NAME
Phone number with area code
Email address
example@example.com
Street Address

Include Building and Apartment number

Street Address Line 2

CityState / Province

Postal / Zip Code
State
ex: NY
Zip code
What is the property?

HouseMobile Home/ TrailerCondoApartment
Is the home ownded by the Individual with the disability?

YESNO
Does the Individual own the land?

YESNO
Date of Birth of the individual with disability

MonthDayYear
DOB
Is the Individual currently receiving:

Medicaid- DCFS,Medicaid WaiverOPWDD ServicesOther
Please list ALL disabilities that apply to the Individual/Consumer
Briefly describe what is needed:*

Ramp, door ways widen for wheelchair, grab bars in bathroom, bathroom modification, rollin shower, parking, etc.0/150
Agency/Business Full Name
Please do not use acronyms
Person submitting the request Name:

First NameLast Name
Business Title/ Relationshop to the individual with the disability
Email address
example@example.com
Phone number
Direct Ext
Street Address
include building #
City
Zip code
Should be Empty:

Architectural Barriers Consultation