Screening Questionnaire 

Thank you for your interest in Rebuilding Together Broward County's critical home repair and accessibility modification services. Rebuilding Together Broward County's model prioritizes critical repairs that correct twenty-five scientifically proven health and safety hazards common in older homes, such as falls, fires, moisture and mold, asthma and allergies, and toxic exposures such as carbon monoxide. We believe a healthy home is clean, dry, pest-free, safe, thermally controlled, ventilated, maintained, and contaminant-free. To prioritize these safety and health improvements, Rebuilding Together Broward County does not perform cosmetic work, such as painting or general remodeling.

Due to the high demand for our programs, we have a prioritized waitlist based on repair needs and the threat to health and safety. By completing this form, you will be added to the the list for review. If you are eligible for one of our programs an intake specialist will contact you to discuss the next steps. Submitting this form does not guarantee services. Please fill out the form completely and to the best of your ability. Please note that wait times for services may exceed two (2) years in some areas depending on need. All homeowners must complete the full application process, including submitting required documents such as proof of income, bank statements, homeowners insurance, and mortgage information to be considered for services. Not all programs require the above documentation, you will be notified by staff if such items are required to provide services.

Please call us at 954-772-9945 or email info@rebuildingtogetherbroward.org with any questions.

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Last Name, First Name *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
City *
Zip Code *
Phone Number  *
Email Address 
Gender *
Marital Status *
Race *
Ethnicity *
Do you have a caregiver? *
If yes, please list their name and date of birth below.
Do you have a physical disability? *
1 point
If yes, please explain the nature of the disability.
1 point
Do you participate in any kind of therapy for your health? examples: dialysis, insulin assistance, respiratory therapy, physical therapy, etc.  *
1 point
Are there children under 18 years of age living in the home? *
1 point
If yes, please list their ages below.
Do you own the home in need of repairs? Note: rental properties rarely qualify for services. *
Do any veterans live in the home? *
1 point
If yes, please select the branch of the military below.
Is your home located in Broward County? *
0 points
Are the repairs needed posing an immediate risk to your health and/or safety?  *
1 point
If yes, please provide a brief explanation below.
Are you or any member of your home 60 years of age or older? *
1 point
Are you currently receiving SNAP benefits? *
Please select your monthly income range below. *
1 point
Are you currently enrolled with Humana? *
1 point
How would you rate your health currently? *
1 point
Compared to a year ago, how would you rate your health? *
1 point
Please select the type of repairs needed. *
Required
Please provide a brief list of repairs you are requesting. *
Please list current health conditions below. *
1 point
How much assistance do you need to bathe? *
Required
How much assistance do you need to get dressed? *
Required
How much assistance do you need to use the bathroom? *
Required
How much assistance do you need to walk? *
Required
How much help do you need cleaning your home? *
Required
How much help do you need preparing meals? *
Required
How much help do you need using transportation? *
Required
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