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Request and Referral Form for Home Checkup Assessment

  1. Healthy Homes of Madison County Logo
  2. Healthy Homes Home Checkup Assessment Request and Referral Form

    Healthy Homes is a free health and safety program that offers participants in-home assessments, interventions, and referrals for asthma, tobacco cessation, indoor air quality, lead, injury prevention, fire safety and other environmental health hazards. 

    Participants receive education, resources, referrals, and FREE products and supplies.  Supplies may include: cleaning supplies, child safety items, as well as smoke, carbon monoxide, and radon detectors, and MORE. 

    Eligible participants must live in Madison County and program services may be prioritized by a city/town focus area, income, or need. 

    The Healthy Homes Program makes two attempts to contact a participant using the contact information provided. 

  3. This is not a home repair or enforcement program; this program provides education and referrals*
  4. Services Requested for:*
  5. Section A. Resident Contact Information
  6. What concerns do you have (check all that apply):*
  7. If completing this form to request services for yourself, skip to Section C to submit this form.
  8. Section B. Referral Entity Contact Information (complete this section only if applicable)
  9. Would you like to be notified if services are provided?
  10. Section C. Submit this form electronically
  11. Leave This Blank:

  12. This field is not part of the form submission.