Home safety intake that captures fall history up front
The intake captures recent fall history, current mobility aids, and who will be home for the visit, plus photos of stairs, bathrooms, and entryways — so you know before you schedule whether the family can act on what you recommend.
The exact intake your home safety assessment leads complete
This is the real 7-question guided intake for Home Safety Assessment — the same flow your customers finish before you ever pick up the phone.
What a qualified home safety assessment lead should tell you
An in-home or in-facility walkthrough that identifies fall hazards, mobility barriers, and needed modifications for an older adult, using the person's fall history, mobility aids, and residence type to scope the visit before it's scheduled.
- This Safety Assessment
- Person Had Fall Or
- Mobility Aids Person Use,
- Residence Be Assessed
- Someone Be Available At
- Have Authority Approve Safety
- Soon Would Like Assessment
The questions your team needs answered
Every home safety assessment intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Who is this safety assessment for? | Distinguishing a self-request, a family member, or a coordinated client changes who you'll need to loop in for approval and follow-up. |
| Has the person had a fall or near-fall in the past year? | A recent fall or near-fall carries the highest weight in this catalog, marking the lead as a genuine safety priority rather than a routine check. |
| What mobility aids does the person currently use, if any? | Segments the lead so you can route, price, and prioritize it correctly. |
| What type of residence needs to be assessed? | Residence type tells you whether you're scoping a private home visit or a facility environment, which typically has different hazards and constraints. |
| Will someone be available at the home during the assessment visit? | Confirming someone will be home avoids scheduling a visit you can't actually complete on arrival. |
| Do you have authority to approve safety modifications recommended after the assessment? | Approval authority determines whether your recommendations can actually be acted on, which is critical when the requester is a coordinator rather than the decision-maker. |
| How soon would you like the assessment to take place? | Segments the lead so you can route, price, and prioritize it correctly. |
How Cliont scores home safety assessment leads
Every answer is weighted automatically — no manual review required.
Value signals
- Person Had Fall Or: yes
- Someone Be Available At: yes
- Have Authority Approve Safety: yes
See the lead your team receives
Home Safety Assessment Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for home safety assessment workflows
| Cliont capability | Home Safety Assessment application |
|---|---|
| Weighted lead scoring | Fall history, home availability, and modification authority carry the highest weights in this catalog, so leads combining all three surface above exploratory or coordinator-only requests. |
| Photo and video capture widget | Collects images of stairs, bathrooms, and entryways plus any mobility equipment already in use, giving you hazard context before you drive to the visit. |
| Conditional routing | Separates requests for single-family homes and apartments from senior living facility requests, which typically require a different assessment scope. |
| CRM delivery | Sends qualified assessments to your CRM with fall history, mobility aids, and approval authority already attached, instead of a bare name and phone number. |
Common home safety assessment lead scenarios
Recent fall, no aids yet
The person has had a fall or near-fall in the past year but currently uses no cane, walker, or wheelchair, signaling a risk profile that warrants a closer look before the visit.
No one confirmed home for the visit
A family submits the request but can't yet confirm someone will be present during the assessment, which the intake flags so you can chase scheduling before dispatching.
Coordinator without approval authority
A care coordinator books on behalf of a client but doesn't have authority to approve any modifications the assessment recommends, so the lead routes with that gap visible instead of hidden until the visit.
Facility resident, not a private home
The request is for someone living in a senior living facility rather than a single-family home or apartment, which changes the scope of hazards you're being asked to evaluate.
Fall history, ready to move now
The person has fallen in the past year, someone will be home, the requester can approve modifications, and they want the visit as soon as possible — the combination that should reach your calendar first.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More senior mobility and safety intake templates
Home Safety Assessment lead-intake FAQs
How does the intake tell me who can actually approve the modifications afterward?
The intake asks directly whether the requester has authority to approve safety modifications, and separately whether the assessment is for themselves, a family member, or a client they coordinate care for. A coordinator without approval authority is still routed to your CRM, but with that gap visible up front.
What happens if the family isn't sure anyone will be home during the visit?
The intake asks whether someone will be available at the home for the assessment. A 'no' or uncertain answer lowers the lead's readiness score so you can confirm scheduling before committing a visit slot.
Does the intake distinguish a private home from a senior living facility?
Yes, the residence-type question separates single-family homes, apartments or condos, and senior living facilities, so you can see the scope of the assessment before you accept it.
Will the intake flag someone who has already had a fall?
Yes, a reported fall or near-fall in the past year is one of the highest-weighted answers in the catalog, so those leads score higher and stand out from routine, exploratory requests.
What photos or documents get collected before I schedule the visit?
You can require photos of stairs, bathrooms, and entryways along with any existing mobility equipment, so you arrive with a sense of the hazards instead of assessing them cold.
How is this different from your Fall Risk Assessment intake?
This intake scopes a full home walkthrough for hazards and modifications, capturing residence type and approval authority, while Fall Risk Assessment focuses more narrowly on the person's physical fall risk itself. Both live in the same category alongside Mobility Equipment Consultation and Aging-in-Place Planning.
Turn home safety assessment visitors into qualified patients
Give every home safety assessment visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.