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.
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*

YesNo
Toileting/Bathing/Self-Care in Bathroom

Yes
Sleeping Routines/Up and About at Night*

YesNo
Sleeping Routines/Up and About at Night

Yes
Completing Daily Living Routines with Auditory Prompts like Laundry/Cooking/Cleaning*

YesNo
Completing Daily Living Routines with Auditory Prompts like Laundry/Cooking/Cleaning

Yes
Taking Medication*

YesNo
Taking Medication

Yes
Falling or Balance*

YesNo
Falling or Balance

Yes
Getting in or Out of Bed or Chair*

YesNo
Getting in or Out of Bed or Chair

Yes
Controlling environment with limited mobility (turning on lights)*

YesNo
Controlling environment with limited mobility (turning on lights)

Yes
Cooking Safety/Meal Prep*

YesNo
Cooking Safety/Meal Prep

Yes
Entering or Exiting the Home/Answering the Door*

YesNo
Entering or Exiting the Home/Answering the Door

Yes
Accessing Help for an Emergency*

YesNo
Accessing Help for an Emergency

Yes
Wandering or Elopement/Running Way or Egress (Leaving the Home)*

YesNo
Wandering or Elopement/Running Way or Egress (Leaving the Home)

Yes
Having Privacy or Being Alone Part or All of Day or Night*

YesNo
Having Privacy or Being Alone Part or All of Day or Night

Yes
Using Tech for social connection with Friends and Family*

YesNo
Using Tech for social connection with Friends and Family

Yes
Select any of the following you might be interested in?

Select all that Apply:
A live webinar for your team presented by SimplyHome*

YesNo
A live webinar for your team presented by SimplyHome

Yes
A phone call with someone from SimplyHome to discuss your situation*

YesNo
A phone call with someone from SimplyHome to discuss your situation

Yes
An email with interactive links and other resources to learn more about our SimplyHome*

YesNo
An email with interactive links and other resources to learn more about our SimplyHome

Yes
Record Type
Owner ID
Jotform Submitted Checkbox

Yes
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?