Screen Reader Mode Icon
This application will help us identify potential participants for the consideration of smart home technology.  This project is grant funded.  The goal of the project is  to help individuals in Rhode Island increase their independence through the use of smart home technology. Information gained from the application will be used to help us provide the most appropriate equipment and support services to participants in the project. All of your information will be kept confidential.  

While funds are available, we will be providing participants with technology that can help increase independence around the home over a 3 month loan period. The purpose of the loan period is to determine what specific smart home technology best fits individual participant’s needs and abilities. At the conclusion of the loan period, we will also help identify potential funding sources to assist in acquiring the equipment that has been identified.  Since privacy can be a concern with smart home technology, we will focus on ensuring privacy and security when setting up these devices for program participants.

During the loan period, there will be an initial home visit scheduled to set up and configure smart home devices.  Support services will be provided throughout the course of the short-term loan period.  When possible, this will be done remotely through video conferencing.  

Please answer the following questions so we may determine if you qualify for assistive technology through this project. 

We very much appreciate your interest and your time in completing this Application.  We will contact you to discuss your participation once we have reviewed the application.

Thank you! 

Question Title

* 1. Are you currently a resident of Rhode Island?

Question Title

* 2. Please provide the information below.

Question Title

* 3. Do you own or rent your home? This will help us determine what modifications are possible in your living space.  Please note that if you are renting, you will be responsible for obtaining written permission from your landlord if modifications to your home/apartment are needed.  We will require a copy for our records.

Question Title

* 4. Do you have any live-in support at home (parents, partner, friend, caretaker)?

Question Title

* 5. Are you currently receiving any therapy services?

Question Title

* 6. What is your disability? 

Question Title

* 7. What are currently some of your strengths and challenges around accessing your environment?

Question Title

* 8. Do you have access to the internet in your home?

Question Title

* 9. On this sliding scale, how comfortable are you utilizing technology?

Not at all comfortable Somewhat comfortable Very comfortable
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 10. Are you currently using any smart technology in your home?

Question Title

* 11. Are you interested in any of the following Smart home Technology? Check  all that apply. 

Question Title

* 12. Are you comfortable with our clinicians coming to your home to install the technology? Please note that we provide our own PPE and follow all CDC Guidelines.

Question Title

* 13. Please provide any additional comments.

Question Title

* 14. Were you referred by anyone?

0 of 14 answered
 

T