ABC Request Form

Architectural Barriers Consultation

Request for services
Architectural Barriers Consultation (ABC) services from TRI are FREE for the homeowner with a disability.

There is a reasonable cost per hour for business owners desiring to make their properties and/or establishment(s) more accessible to people with disabilities.

After you have submitted 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.

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 (Consumer) with a disability requesting services.I am a family member/friend requesting services on behalf of the consumer.I am an agency requesting services on behalf of my client.I am a BUSINESS OWNER requesting services for my own property (This will skip the following questions for a Consumer).
The Individuals information collected on this form is to remain confidential unless the individual/consumer signs consent for the Barrier-Free Architectural Consultant or other authorized TRI Advocate 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.
Name of the Consumer- the individual with the disability*

PrefixConsumer FIRST NAMEMiddle InitialConsumer LAST NAME
Date of Birth of the individual with disability*

MonthDayYear
DOB
Consumer's Phone number with area code*
Consumer's 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/Consumer?*

YESNO
Does the Individual own the land?*

YESNO
Is the Individual currently receiving:*

Medicaid- DCFS,Medicaid WaiverOPWDD ServicesOther
Please list ALL disabilities that apply to the Individual/Consumer*
If you are completing this form on behalf of the Individual, please provide your contact information below:
You've selected that you are a Business Owner inquiring about how to make your property and/or establishment more accessible for people with disabilities. Please provide your contact information.

If you have not received a call or email response from Patrick Muller within 10 business days, please contact: (845) 452-3913 ext.110 or p.muller@taconicresources.org
Your Name*

First NameLast Name
Relationship to the Individual
Email address*
example@example.com
Phone number*
Direct Ext
Agency/Business Full Name
Please do not use acronyms
Street Address*
include building #
City*
Zip code*
Briefly describe what is needed:*

Ramp, door ways widen for wheelchair, grab bars in bathroom, bathroom modification, rollin shower, parking, etc.0/150
Should be Empty:

Architectural Barriers Consultation