Home Safety and Comfort Referral Form

Patient/Client Information


Primary Caregiver Information (If applicable)

Check boxes for home safety and comfort solutions that may be applicable for your patient/client

General in-home assessment

Technology Solutions

Personal emergency alert systems

Fall detection and alert systems

Medication reminders

Whole-home sensor-based activity monitoring

Voice-activated smart lighting and control

Video doorbell and/or remote unlocking doors

Telephone Consultation

Mobility Solutions


Reclining or zero-gravity lift chair

Wheelchair and/or threshold ramps

Patient transfer lift for homes

Power scooter or motorized wheelchair

Bathroom safety assists or shower remodel for access

Home modification for accessibility

Other home automation

Referred By:

For a LiveWell

Representative to Contact You: