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2. Are you looking for suggestions on ways to reduce falls and improve fire safety in your home?

   
   

   The Bothell Fire Department offers home safety evaluations that include a visit from our Community Risk Reduction staff to assist with smoke and carbon monoxide alarms and evaluate home fall hazards. This program is for adults over 65 years of age, living independently, and who have fallen in or around their home.

   We can also help install alarms for those who cannot afford them or troubleshoot your existing alarms. We are unable to assist with rewiring of hardwired smoke alarms.

   Our team will help identify steps you can take and changes you can make to reduce the risk of falling.  We can also help connect you with local services that promote independence and allow you or your loved one to age in place for as long as possible.  

4. Contact Information
6. Name of Person Completing the Form:*
8. Email:*
9. Phone:*
11. What is your relationship to the homeowner or tenant?*
13. Home Information
15. Address*
17. City*
18. State
19. Zip Code
21. Age(s) of People Living in the Home:*
23. Dwelling Type:*

    1. Single Family Home
    2. Apartment
    3. Mobile Home

    1. Independent Senior Living
    2. Other
25. Number of Bedrooms in the Home:*
26. Number of Current Smoke Alarms:*
27. Number of Carbon Monoxide Alarms:*
29. Visit Information
31. Why are you requesting a home safety visit? What special concerns, risks, or health issues do you have?*
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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