My home evaluation

Think about each room in your home and list what is working or not working for you below: What is working? What is not working? This form will help you evaluate what is working and not working both inside and outside your home and in your community. It will help you identify things that are working so that they can become a part of your housing plan and those that are not working so that you can address them in the housing plan. If you need help completing this form, please ask your caregiver or someone on your support team for help filling it out.

Think about each room in your home and list what is working or not working for you below:

• Bedroom (number, size)
• Kitchen (size, microwave, dishwasher)
• Bathroom (number, size, tub/shower)
• Living room (size, cable, internet)
• Laundry room (access, washer, dryer)
• Storage (closets, shelves)

Think about everything outside of your home and in your community. List what is working or not working for you below:

• Outside space (lawn, BBQ, deck)
• Noise (near highway, train tracks, bars)
• Mailbox (location, access)
• Garbage/Recycle (bins, services)

Think about how easy it is for you to get to and into your home and how safe you feel both inside and outside your home. List what is working or not working for you below:

• Location (near bus stops, activities, amenities)
• Accessibility (stairs, elevator, ramp)
• Privacy (building buzzer, windows)
• Landlord/Apartment Super (availability, services)
• Security (locks, alarm system, etc.)
• Emergency (fire exits, smoke alarms)

Think about anything else that is important to you in your home or where you live. List what is working or not working for you below:

• Pets (if currently have or plan to have)
• Restrictions in house (visitors, smoking, etc.)

Action Plan