Request for Information

Request for Information

Please submit your information below using this form. One of our team members will contact you and provide you with additional information regarding your interests about SimplyHome.
Your Information:
Your First Name
Your Last Name
Title
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How'd you hear about us?
Organization Information
Name of Organization
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
State
State
What are your organizational goals working with SimplyHome?
What funding sources are available to support your organization?
(example: Waiver funding, Grantmoney, other sources)
What concerns can we help you address?

Select All that Apply:
Toileting/Bathing/Self-Care in Bathroom
Toileting/Bathing/Self-Care in Bathroom
Sleeping Routines/Up and About at Night
Sleeping Routines/Up and About at Night
Completing Daily Living Routines with Auditory Prompts like Laundry/Cooking/Cleaning
Completing Daily Living Routines with Auditory Prompts like Laundry/Cooking/Cleaning
Taking Medication
Taking Medication
Falling or Balance
Falling or Balance
Getting in or Out of Bed or Chair
Getting in or Out of Bed or Chair
Controlling environment with limited mobility (turning on lights)
Controlling environment with limited mobility (turning on lights)
Cooking Safety/Meal Prep
Cooking Safety/Meal Prep
Entering or Exiting the Home/Answering the Door
Entering or Exiting the Home/Answering the Door
Accessing Help for an Emergency
Accessing Help for an Emergency
Wandering or Elopement/Running Way or Egress (Leaving the Home)
Wandering or Elopement/Running Way or Egress (Leaving the Home)
Having Privacy or Being Alone Part or All of Day or Night
Having Privacy or Being Alone Part or All of Day or Night
Using Tech for social connection with Friends and Family
Using Tech for social connection with Friends and Family
Select any of the following you might be interested in?

Select all that Apply:
A live webinar for your team presented by SimplyHome
A live webinar for your team presented by SimplyHome
A phone call with someone from SimplyHome to discuss your situation
A phone call with someone from SimplyHome to discuss your situation
An email with interactive links and other resources to learn more about our SimplyHome
An email with interactive links and other resources to learn more about our SimplyHome
Record Type
Owner ID
Jotform Submitted Checkbox
Should be Empty:

Request for Information

Your Information:

Organization Information

What concerns can we help you address?

Select any of the following you might be interested in?