Intake Form | Steady Home Preparedness

Contact info

So I can confirm your appointment.

Full name

Email

Phone

Best way to reach you

Street address (for in-home visits)

City

County

72-hour kits and storage needs depend on every person (and pet).

Adults (18–64)

Children (under 18)

Seniors (65+)

Children's ages (optional)

Pets (optional)

Any special considerations?

Infant / formula Daily medications Refrigerated meds Powered medical equipment Limited mobility Food allergies / diet Sensory / developmental

Anything I should know about those needs? (optional)

Home type

Best guesses are fine. This helps me plan how long your visit will take.

72-hour kits

None yet Some of us Everyone, not checked lately Everyone, up to date

Stored water

Food storage

Do you already have any of these?

First aid kit Backup power Alternate cooking Alternate heat Document copies Written family plan Know utility shut-offs

What concerns you most?

Earthquake Wildfire / evacuation Winter storm / outage Flooding Job loss / financial Illness / pandemic Just want to be organized

Roughly how much could you put toward supplies over the next year? So your buying plan is realistic. There's no wrong answer.

You'll pay securely through Stripe on the next screen.

Have you used our services before?

No, first time Yes, returning client

Visit format

In-home Video call Either works

When are you usually available?

Weekday mornings Weekday afternoons Weekday evenings Saturdays

How did you hear about us? (optional)

Anything else you'd like me to know? (optional)