CONTACT US

Please Allow Us to Assist You.

Susan Mack, OTR/L, NAHB/CAASH and CAPS

NBCOT/Registered/CA. Licensed Occupational Therapist
National Association of Home Builders / Certified Active Adult Specialist in Housing
National Association of Home Builders /Certified Aging-In-Place Specialist

Name

E-Mail Address

Mailing Address

City

State

Zip

Country

Telephone #

Fax #

Best Way to Contact You?

Are You Seeking A Universal Design Consulant?

Are You Seeking A Universally Designed House?

For Whom are You Seeking Services and / or Housing?

In What Geographical Area are You Looking?

How Soon Do You Need to Move Into a New Home?

What Services and / or Housing Features Are You Seeking?
Assistive Technology Consultation	Caregiver Education
Long Term Care Planning Assistance	Workplace Assessment & Modifications
Product Design Consultation	Educational Programs
Home Assessment & Modifications	Home Selection Assistance
Single Family Housing	Multi-Family Housing
Minimum Number of Bedrooms Needed?
Number of Bathrooms?
Approximate Number of Square Feet Desired?

Does Anyone In Your Family Have Special Needs?

Yes No

If Yes, What Are Their Needs?

Does Anyone Have Difficulty With:

Walking?

Climbing Stairs?

Reaching for Things?

Getting Up and Down From Low Chairs?

Getting In and Out of the Bathtub?

Picking Things Up From the Floor?

Vision?

How Did You Hear About Us?