SimplyHome Product Intake Forms

If you are interested in exploring assistive technology to promote an individual’s independence, the first step is completing an online intake form. Once our customer service team receives the completed intake form, we will schedule a complimentary over-the-phone assessment. This 30-min. assessment is a casual conversation about the individual/family's priorities, and how assistive technology may help achieve those goals. Based on the information shared in the assessment, we will then create a system recommendation and a quote, customized specifically for the individual/family. This is a starting point; the system recommendation and quote can always be updated to reflect the changing goals of an individual.


Intake Forms:

SimplyHome System Intake

Medication Dispenser Intake

TeleHealth Intake

Environmental Controls System Intake

(PERS) Personal Emergency Response System Intake


Below is a description of the devices we utilize to achieve outcomes, and some key points to review when considering technology for an individual.


SimplyHome System

Concerns Addressed:SimplyHome systems can address concerns for individuals who desire to learn independent living skills, such as cooking safety and meal preparation, hygiene routines, medication adherence, and completing other activities of daily living.

Custom Sensors and Alerts: Each SimplyHome system is tailored to the individual’s concerns and may include motion sensors, door/window sensors, chair/bed pressure pad sensors, stove sensors, smoke detectors, incontinence pads, panic pendants and water sensors. The system is programmed to alert responders of potential problems via email, texts, or phone calls.

Who Do We Consider?

  • Individuals who are being considered for independent living, supported settings, or transitional homes.

  • Individuals who have 24/7 staffing for “just in case” situations, but do not need constant supervision.

  • Individuals who have skills to live independently but need guidance on behavioral outcomes.

  • Individuals who have disabilities, joint/muscular difficulties, or visual issues that affect balance or mobility.

  • Individuals who desire to learn independence and safety in meal preparation and cooking.

  • Individuals who are at risk for falling, wandering, or egress, or who engage in unsafe behaviors at night.

  • Individuals who may need assistance while in the bathroom or need prompting with hygiene routines.

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Medication Reminder System:

Our medication dispenser is a tamper-proof, programmable unit that generates alerts to staff or caregivers about medication non-compliance or delays. Staff have access to a website that logs information about when the medication was accessed.

Who Do We Consider?


Telehealth: Managing Chronic Conditions

Our Telehealth program includes a base unit that is connected (via Bluetooth or a cord) to monitoring tools (blood pressure cuff, pulse oximeter, glucometer, spirometer, weight scale). Telehealth promotes proactive health management by recording and documenting daily vital signs.

Who Do We Consider?

  • Individuals monitoring blood glucose, blood pressure, heart rate, weight, pulse oximetry.

  • Individuals with congestive heart failure, diabetes, asthma, and/or hypertension.


Environmental Controls:

Environmental controls are created by pairing a tablet with other technology that allows the tablet to have access to home features such as lighting, thermostat, television, and door openers.

Who Do We Consider?

  • Individuals with physical disabilities or paralysis who can activate a screen/switch by touch, eyes, or voice.

  • Individuals with fine motor difficulties due to joint/muscular issues.

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Personal Emergency Response System (PERS): 

The PERS is our entry-level system that uses a wireless pendant to activate a notification to a call center or a responder of your choice. The pendant can be pressed at any time.

Who Do We Consider?

  • Individuals who are capable of pressing a button to call for help.

  • Individuals who may be at risk for falling.

  • Individuals who have visual perception issues that impact balance and mobility.


Not sure which technology is right for you? Get in touch with us today and receive a free assessment.