Beyond Access Client Intake Form

Intake Form for a Facility Assessment

Please complete this form to the best of your ability. If you have multiple facilities, please fill out this form for each one. When you complete this form and press "submit" you should be redirected to a page with a link to repeat this form. You will also receive an email with a PDF version of this form attached for your records.
Facility Name*
Address*
Contact*
First and Last name
Phone *
Best number to reach you during business hours
Email*
example@example.com
Are you the owner?*

YesNo
If no please specify
What is the use of the facility?*

Private Business or NonprofitPrivate Multi-Family HousingPublic (Goverment) HousingState, County or City Government
What year was the facility originally constructed?*
If unsure, your best estimate
Have there been any additions or alterations to the facility since 1991?*

YesNoUnknown
Is this part of any litigation or potential lawsuit?*

YesNoUnsure
Number of buildings*
Number of stories per building:
Building 1*
Building 2
Building 3
Building 4
Number of entrances per building:
Building 1*
Building 2
Building 3
Building 4
Number of public elevators*
Number of ramps*
How many public restrooms are there?*
Number of multi-stall restrooms
Number of single-user toilet rooms
How many total parking stalls serve the facility*
Please tell us your budget for this facility assessment *
Do you have any additional training or technical assistance requests?
Any Additional Comments or Items of Note:
Should be Empty:

Intake Form for a Facility Assessment