Smart Technology in Home Implementation Application

Applicant Information

Name

Date of Birth (MM/DD/YYYY)

Primary Contact

Relationship/Title

Street Address

City

State

Zip Code

Phone Number

Email Address

Seminar Attended

Associated Entity

Disability/SMART Tech Information

Diagnosis of Disability/Disabilities

Current Device/Equipment In Home

Do you currently have Internet/Wi-Fi capabilities within your home?

Device/Equipment/Service Requested

Explain how this SMART Technology will assist you with your disability.

How will this device or service help to better support your health care needs, or personal safety?

How will this device or service improve your independence, productivity, or quality of life?

How did you determine that this is the SMART Technology you need? Select all that apply.Evaluation by a Doctor/TherapistRecommendation (Enter Name Below)Tried the Device/ServiceOther (Specify Below)

Recommended By/Other

See How We Can Support You!

PA Inclusive is a provider of services for people with disabilities who have a ‘Waiver for Service’ through the Pennsylvania Office of Developmental Programs (ODP). We provide In-Home and Community Supports, Companion Services, Supported Employment, and Supported Living Services.

SMART Technology In-Home Implementation Application

Applicant Information

Disability/SMART Tech Information

See How We Can Support You!

Main Office

Lehigh Valley
Regional Office

Berks County
Regional Office

Pocono
Regional Office

Carbon County Office

Schuylkill County Regional Office,
Pottsville CollegeTown Alvernia University