Healthy Home Safety Check

To request a visit from our Healthy Neighborhoods Program, please complete the fields below, and we will contact you via the phone number or email address you provide.

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Who is completing this request?*

Myself

Code Enforcement

Early Intervention Provider

Health Care Provider

WIC

Anonymous

DSS

Other

How did you hear about Home Safety Checks?*

My Medical Provider

Facebook

Radio Advertisement

My Neighbor

Family Member

Other

Do you rent or own your home?*

Rent

Own

First Name*?

Last Name*?

How would you prefer us to contact you?

Phone

Email

Either

Email Address

Phone Number

Please share any questions, concerns or comments here: