Intake Form

Aging in Place

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Patient First Name*
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Patient Last Name*
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Patient Email*
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Patient Phone Number*
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Caretaker First Name
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Caretaker Last Name
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Caretaker Email
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Caretaker Phone Number
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Would you like to request a virtual or in-person appointment?*
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Do you currently experience any physical limitations making your environment difficult to access?*
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Do you currently have a specific diagnosis that will lead to progressive loss of physical or cognitive functioning?*
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Do you have any additional diagnoses from a medical professional that you'd like to share?*
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Are you currently taking any medications that improve or hinder your ability to perform daily tasks?*
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Have you experienced any falls?*
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Do you currently have a referral to, or are you receiving, any home health or outpatient services from a healthcare provider?*
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Have you been told by a medical professional to avoid any specific activities, movements, or positions?*
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What specific concerns or goals would you like us to focus on during your consultation?
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Additional Notes or Comments
Thank you!
We’re so glad you reached out. We’ll review your form and be in touch soon to guide you through the next steps.
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Testimonials

Patients Review

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“We had no idea how much our home setup was affecting our daily life until our consult with My Home Works. After a few simple changes, my husband is more comfortable, and I feel so much more at ease knowing we’re prepared for the future.”

Maggie T.
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Age in Place
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“I was dealing with back pain from working at my kitchen table all day. The virtual consultation was so easy, and the follow-up plan was detailed and practical. I genuinely feel better working now.”

Jason L.
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Home Office
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“The suggestions we got for our son’s sensory space have made a huge difference. It’s easier for him to regulate and easier for us to support him at home.”

Naomi K.
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Pediatric Sensory
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“I didn’t qualify for traditional home health support, but My Home Works filled that gap perfectly. I felt heard, supported, and empowered to make meaningful changes in my space.”

Elena V.
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Post-Recovery
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“What I appreciated most was how non-intimidating the whole process felt. No sales pitch—just thoughtful, professional help that truly made our home feel safer.”

Thomas M.
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Family Caregiver
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“I didn’t realize how many small things in my home were slowing me down. The consult helped me see my space in a new light, and the recommendations were so doable—even on a budget.”

Paul D.
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Age in Place
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“We were overwhelmed trying to find the right setup for our daughter’s play space. My Home Works gave us simple, expert guidance that made everything feel more manageable—and more joyful.”

Rachel & Tim S.
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Pediatric Spaces
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