Home Health Assessment Registration Form

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Introduction
Thank you for your interest in the American Lung Association's free Healthy Home Check-up. Please help us learn a little bit more about you and your home environment by answering the questions below. Once you complete this online registration form, a staff person will reach out to you via telephone to schedule an in-person visit and answer any questions.

All questions on this form are optional, except for those marked with an asterisk (*). These questions are required because they provide information necessary for us to follow-up with you and best serve you and your family. All information will be maintained securely.

If you would prefer to complete this registration form over the phone, please contact Casey Coulombe at (206) 512-3282.
Please use the MM/DD/YYYY format.
Calendar
2. Contact Information
Please use the following format: 123-456-7890
3. Why are you requesting a Healthy Home Check-up?
4. How did you hear about the Master Home Environmentalist (MHE) program?