Equipment Request Form

Equipment Request
Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the person completing this form the individual receiving the equipment? Yes / No
How did you hear about / get referred to Butler Rescue Hands?
Fall & Safety History
Has the individual fallen within the past 12 months?
If yes, approximately how many falls?
Does the individual currently feel unsteady while standing or walking
Does the individual currently use any of the following?
Does the individual need assistance with:
Are any of the following concerns present in the home?
Living Situation
Appointment
Type of Equipment Requested
Do you require GPS tracking capability?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
** Please allow up to 24 hours for a representative to contact you. For urgent requests, please call our office directly at (203) 514-0031**
Submission of this form does not guarantee equipment approval, funding, or installation. Equipment may be purchased privately or, when applicable, funded through an approved waiver or program. Waiver-funded requests may require authorization before equipment can be ordered. A Butler Rescue Hands representative will contact you to review your request, discuss available options, and explain the next steps.
Should be Empty:

Equipment Request