Home Modifications Program form

Thank you for your interest in adding your home modification program or company to our National Directory. Please complete the form below and press “send.” We will review your request and contact you regarding your submission status within one week. Entries must fit within the scope of the National Directory on Home Modification Resources. Thank you!

1. Name

Name of home mods. program *

Sponsor

Director

Phone No. *
(Format xxx-xxx-xxxx)

Email *

Website *

Address *

No. of paid staff (home mods.)

No. of persons served per year

Primary target population

Date established

No. of clients

Most common home mods/repairs provided

Total budget

funding sources(S)

Is your organization non-profit?
yesno

does your program provide an environmental assessment?
yesno

Assessor

Special features add: (e.g., use of an occupational therapist; free assessment; creative funding; volunteers, etc…)