Reliable Living - Independent Living Services
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Name *
Telephone Number *
Address *
City *
Province / State
Postal / Zip Code *
Email Address

 

Where did you get our information?
Newspaper Ad
Family Care Guide
Helps Here Guide
Web Search
Healthcare Professional
Friend of Family Member
Homecare Worker
Radio
Other

 

Will a family member contact us on your behalf?
(if so please provide their contact information)

Family Member's Name
Family Member's Telephone Number

 

Services Required
 Exterior Ramp
 Exterior Wheelchair Lift Walkway
 Interior Stair Lift
 Interior Elevator
 Washroom Modification
 Kitchen Modification
 Non-Slip Flooring
 Home Safety Modification

Other: 

 

Additional Information
Is an occupational therapist or other health care professional involved in the case?   (if so please provide their contact information)

Health Care Professional's Name
Health Care Professional's Telephone Number

 

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