AGC Home Safety Assessment 2026

Home Safety Assessment

This form is made to be filled out and submitted electronically. If you prefer to fill out paper copies and want to print these forms ahead of time, please email alwaysgoodcompanyhomecare@gmail.com for a printer friendly version, otherwise Elsie will bring paper copies to the initial inteview.
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client’s Name

First NameLast Name
Key: Check box if satisfactory; mark "n/a" if not applicable
Environment
Stairway:
Home:
Recommendations:
Medication
Recommendations:
Fire Safety
Recommendations:
Bath / Bedroom
Hazard-free access to:
Recommendations:
Kitchen
Recommendations:
The undersigned certifies that he/she has read and received a copy of the foregoing, and is the Client, or is duly authorized by the Client's general agent to execute the above and accept its terms.
Client’s Name

First NameLast Name
Signature of Client:
Name of Client’s Representative

First NameLast Name
Signature of Client’s Representative:
Name of AGCHC Representative:

First NameLast Name
Should be Empty: