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form_title=Disability Planner form_header=7963 Please identify the disabilities which need to be addressed. (Choose all that apply)*= [] "Mobility/agility (wheelchair, walker) [] Hearing [] Sight [] Strength/range of motion (lifting, reaching, bending) [] Sense of touch/dexterity (turning knobs) [] Smell [] Cognition (dementia, Alzheimer's) [] Other" Please specify the type of residence.*= () "One-story single family home () Two-story single family home () Unit on ground floor of multi-family residence (condo, townhouse, apartment etc.) () Unit on upper floor of multi-family residence (condo, townhhouse, apt., etc.) () Separate apt./quarters adjacent to family residence () Other"

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