{"id":17,"date":"2025-11-13T12:06:42","date_gmt":"2025-11-13T12:06:42","guid":{"rendered":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/get-care\/"},"modified":"2025-11-13T12:36:35","modified_gmt":"2025-11-13T12:36:35","slug":"get-care","status":"publish","type":"page","link":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/get-care\/","title":{"rendered":"Get Care"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"17\" class=\"elementor elementor-17\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-294508ac e-flex e-con-boxed e-con e-parent\" data-id=\"294508ac\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-4aa4b3ea e-con-full e-flex e-con e-child\" data-id=\"4aa4b3ea\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9df971f elementor-widget elementor-widget-heading\" data-id=\"9df971f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Request Care<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-55cc8501 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"55cc8501\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Help us understand your situation and current needs. Then we\u2019ll set up a free phone consultation so you can get the right support and care services to live well and age successfully at home.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-51f25620 elementor-alert-info elementor-widget elementor-widget-alert\" data-id=\"51f25620\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"alert.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-alert\" role=\"alert\">\n\n\t\t\t\t\t\t<span class=\"elementor-alert-title\">Note:<\/span>\n\t\t\t\n\t\t\t\t\t\t<span class=\"elementor-alert-description\">This form is fully customizable and seamlessly integrates with major CRMs, Google Docs, and more for automated data transfer. For your convenience, form fields are currently set as optional, allowing you to easily navigate through all steps without completing the form.<\/br>\n<b>Optional features: <\/b>Price calculation, payment collection, eSign, PDF Export, Recurring payment collections, etc. <\/span>\n\t\t\t\n\t\t\t\t\t\t<button type=\"button\" class=\"elementor-alert-dismiss\" aria-label=\"Dismiss this alert.\">\n\t\t\t\t\t\t\t\t\t<span aria-hidden=\"true\">&times;<\/span>\n\t\t\t\t\t\t\t<\/button>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3e971a91 ha-has-bg-overlay elementor-widget elementor-widget-shortcode\" data-id=\"3e971a91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-145 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-145\" data-uid=\"6a202c3f35103\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-145\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-145 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"145\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a202c3f35103\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-pagination-progress\" aria-hidden=\"true\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-145--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-145--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Finish\"\n\t\t\t\tdata-actual-label=\"Page 1\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a202c3f35103\" id=\"forminator-field-name-1_6a202c3f35103-label\" class=\"forminator-label\">Your Full Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_6a202c3f35103\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a202c3f35103\" id=\"forminator-field-email-1_6a202c3f35103-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_6a202c3f35103\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a202c3f35103\" id=\"forminator-field-text-1_6a202c3f35103-label\" class=\"forminator-label\">What&#039;s the zip code of the person who needs care?<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a202c3f35103\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a202c3f35103-label\"><span id=\"forminator-radiogroup-radio-1-6a202c3f35103-label\" class=\"forminator-label\">Who needs care or help at home?<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a202c3f35103\" class=\"forminator-radio forminator-radio-inline\" title=\"A loved one\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">A loved one<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a202c3f35103\" class=\"forminator-radio forminator-radio-inline\" title=\"Myself\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Myself<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-6a202c3f35103\" class=\"forminator-radio forminator-radio-inline\" title=\"A client\"><input type=\"radio\" name=\"radio-1\" value=\"A-client\" id=\"forminator-field-radio-1-3-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">A client<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-6a202c3f35103\" class=\"forminator-radio forminator-radio-inline\" title=\"Other\"><input type=\"radio\" name=\"radio-1\" value=\"Other\" id=\"forminator-field-radio-1-4-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-1-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Other<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-145--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-145--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Page  1\"\n\t\t\t\tdata-actual-label=\"Page 2\"\n\t\t\t\tdata-name=\"page-break-2\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a202c3f35103-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a202c3f35103-label\" class=\"forminator-label\">Click on the best option for your current needs and we\u2019ll ask for more details later.<\/span><label id=\"forminator-field-checkbox-1-1-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-1-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Memory Care At Home\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-1-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Memory Care At Home<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-2-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Support For Chronic Conditions\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-2-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Support For Chronic Conditions<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-3-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Post Hospitalization Support\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Post-Hospitalization-Support\" id=\"forminator-field-checkbox-1-3-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-3-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Post Hospitalization Support<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-4-6a202c3f35103\" class=\"forminator-checkbox\" title=\"End-of-life Care\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"End-of-life-Care\" id=\"forminator-field-checkbox-1-4-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-4-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">End-of-life Care<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-5-6a202c3f35103\" class=\"forminator-checkbox\" title=\"24\/7 Complex Care\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"24-7-Complex-Care\" id=\"forminator-field-checkbox-1-5-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-5-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">24\/7 Complex Care<\/span><\/label><label id=\"forminator-field-checkbox-1-6-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-6-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Companion Care\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Companion-Care\" id=\"forminator-field-checkbox-1-6-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-6-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Companion Care<\/span><\/label><label id=\"forminator-field-checkbox-1-7-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-7-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Life Care Planning\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Life-Care-Planning\" id=\"forminator-field-checkbox-1-7-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-7-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Life Care Planning<\/span><\/label><label id=\"forminator-field-checkbox-1-8-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-8-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Help Around The Home\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Help-Around-The-Home\" id=\"forminator-field-checkbox-1-8-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-8-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Help Around The Home<\/span><\/label><label id=\"forminator-field-checkbox-1-9-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-9-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Companion Care\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Companion-Care\" id=\"forminator-field-checkbox-1-9-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-9-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Companion Care<\/span><\/label><label id=\"forminator-field-checkbox-1-10-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-10-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Frailty Or Fall-risk Support\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Frailty-Or-Fall-risk-Support\" id=\"forminator-field-checkbox-1-10-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-10-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Frailty Or Fall-risk Support<\/span><\/label><label id=\"forminator-field-checkbox-1-11-6a202c3f35103-label\" for=\"forminator-field-checkbox-1-11-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Adults-with-disabilities Support\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Adults-with-disabilities-Support\" id=\"forminator-field-checkbox-1-11-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-1-11-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Adults-with-disabilities Support<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-2_6a202c3f35103\" id=\"forminator-field-first-name-2_6a202c3f35103-label\" class=\"forminator-label\">What is the care recipient\u2019s first name?<\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"E.g. John\" id=\"forminator-field-first-name-2_6a202c3f35103\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-2_6a202c3f35103\" id=\"forminator-field-last-name-2_6a202c3f35103-label\" class=\"forminator-label\">What is the care recipient\u2019s last name?<\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"E.g. Doe\" id=\"forminator-field-last-name-2_6a202c3f35103\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-145--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-145--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Page  2\"\n\t\t\t\tdata-actual-label=\"Page 3\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a202c3f35103-label\"><span id=\"forminator-radiogroup-radio-2-6a202c3f35103-label\" class=\"forminator-label\">When do you need to start care?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a202c3f35103\" class=\"forminator-radio\" title=\"Immediately\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Immediately<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a202c3f35103\" class=\"forminator-radio\" title=\"In the Coming Weeks\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">In the Coming Weeks<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-6a202c3f35103\" class=\"forminator-radio\" title=\"Planning for the Future\"><input type=\"radio\" name=\"radio-2\" value=\"Planning-for-the-Future\" id=\"forminator-field-radio-2-3-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Planning for the Future<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-6a202c3f35103\" class=\"forminator-radio\" title=\"Not Sure\"><input type=\"radio\" name=\"radio-2\" value=\"Not-Sure\" id=\"forminator-field-radio-2-4-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not Sure<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a202c3f35103-label\"><span id=\"forminator-radiogroup-radio-3-6a202c3f35103-label\" class=\"forminator-label\">Do you know how much care you\u2019ll need?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a202c3f35103\" class=\"forminator-radio\" title=\"A few hours a day\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">A few hours a day<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a202c3f35103\" class=\"forminator-radio\" title=\"Most of the day\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Most of the day<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-6a202c3f35103\" class=\"forminator-radio\" title=\"Around the clock support\"><input type=\"radio\" name=\"radio-3\" value=\"Around-the-clock-support\" id=\"forminator-field-radio-3-3-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Around the clock support<\/span><\/label><label id=\"forminator-field-radio-3-label-4\" for=\"forminator-field-radio-3-4-6a202c3f35103\" class=\"forminator-radio\" title=\"Not sure\"><input type=\"radio\" name=\"radio-3\" value=\"Not-sure\" id=\"forminator-field-radio-3-4-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-3-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not sure<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a202c3f35103-label\"><span id=\"forminator-radiogroup-radio-4-6a202c3f35103-label\" class=\"forminator-label\">Are you planning for long-term care?<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a202c3f35103\" class=\"forminator-radio\" title=\"No, just a few weeks\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No, just a few weeks<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a202c3f35103\" class=\"forminator-radio\" title=\"Yes, we need a long-term solution\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, we need a long-term solution<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-6a202c3f35103\" class=\"forminator-radio\" title=\"Not sure\"><input type=\"radio\" name=\"radio-4\" value=\"Not-sure\" id=\"forminator-field-radio-4-3-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not sure<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-145--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-145--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"Page  3\"\n\t\t\t\tdata-actual-label=\"Page 4\"\n\t\t\t\tdata-name=\"page-break-4\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a202c3f35103-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a202c3f35103-label\" class=\"forminator-label\">Can you give us more details on the care you\u2019ll need?<\/span><label id=\"forminator-field-checkbox-2-1-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-1-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Personal Care (Help With Bathing, Grooming, Dressing, etc.)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-1-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Personal Care (Help With Bathing, Grooming, Dressing, etc.)<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-2-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Supportive Care Within the Home (Meal Preparation, Companionship, etc)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-2-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Supportive Care Within the Home (Meal Preparation, Companionship, etc)<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-3-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Lifestyle Support (Help With Planning and Scheduling Social Events and Activities)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Lifestyle-Support-(Help-With-Planning-and-Scheduling-Social-Events-and-Activities)\" id=\"forminator-field-checkbox-2-3-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-3-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lifestyle Support (Help With Planning and Scheduling Social Events and Activities)<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-4-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Transportation (Shopping, Errands, Medical Appointments, Social Events)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Transportation-(Shopping,-Errands,-Medical-Appointments,-Social-Events)\" id=\"forminator-field-checkbox-2-4-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-4-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Transportation (Shopping, Errands, Medical Appointments, Social Events)<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-5-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Memory Care With a Diagnosis (Alzheimer&#039;s or Other Type of Dementia)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Memory-Care-With-a-Diagnosis-(Alzheimer&#039;s-or-Other-Type-of-Dementia)\" id=\"forminator-field-checkbox-2-5-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-5-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Memory Care With a Diagnosis (Alzheimer's or Other Type of Dementia)<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-6-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Memory Care Without a Diagnosis (Confusion, Cognitive Decline, Memory Problems)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Memory-Care-Without-a-Diagnosis-(Confusion,-Cognitive-Decline,-Memory-Problems)\" id=\"forminator-field-checkbox-2-6-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-6-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Memory Care Without a Diagnosis (Confusion, Cognitive Decline, Memory Problems)<\/span><\/label><label id=\"forminator-field-checkbox-2-7-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-7-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Mobility Support (Help Getting Out of Bed, Going to the Bathroom, or Walking Safely With or Without a Walker)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Mobility-Support-(Help-Getting-Out-of-Bed,-Going-to-the-Bathroom,-or-Walking-Safely-With-or-Without-a-Walker)\" id=\"forminator-field-checkbox-2-7-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-7-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Mobility Support (Help Getting Out of Bed, Going to the Bathroom, or Walking Safely With or Without a Walker)<\/span><\/label><label id=\"forminator-field-checkbox-2-8-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-8-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Total Body, Chairbound and Bedbound Support\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Total-Body,-Chairbound-and-Bedbound-Support\" id=\"forminator-field-checkbox-2-8-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-8-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Total Body, Chairbound and Bedbound Support<\/span><\/label><label id=\"forminator-field-checkbox-2-9-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-9-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Companionship, Social Engagement, and Cognitive Stimulation\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Companionship,-Social-Engagement,-and-Cognitive-Stimulation\" id=\"forminator-field-checkbox-2-9-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-9-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Companionship, Social Engagement, and Cognitive Stimulation<\/span><\/label><label id=\"forminator-field-checkbox-2-10-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-10-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Coordination and oversight of overall wellness\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Coordination-and-oversight-of-overall-wellness\" id=\"forminator-field-checkbox-2-10-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-10-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Coordination and oversight of overall wellness<\/span><\/label><label id=\"forminator-field-checkbox-2-11-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-11-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Safety Observation or Wellness Checks\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Safety-Observation-or-Wellness-Checks\" id=\"forminator-field-checkbox-2-11-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-11-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Safety Observation or Wellness Checks<\/span><\/label><label id=\"forminator-field-checkbox-2-12-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-12-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Medication Monitoring or Management\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Medication-Monitoring-or-Management\" id=\"forminator-field-checkbox-2-12-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-12-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Medication Monitoring or Management<\/span><\/label><label id=\"forminator-field-checkbox-2-13-6a202c3f35103-label\" for=\"forminator-field-checkbox-2-13-6a202c3f35103\" class=\"forminator-checkbox\" title=\"None\/Other\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"None-Other\" id=\"forminator-field-checkbox-2-13-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-2-13-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">None\/Other<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-145--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-145--page-4-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"4\"\n\t\t\t\tdata-label=\"Page  4\"\n\t\t\t\tdata-actual-label=\"Page 5\"\n\t\t\t\tdata-name=\"page-break-5\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-6a202c3f35103-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a202c3f35103-label\" class=\"forminator-label\">CheckboxDo you need any additional services?<\/span><label id=\"forminator-field-checkbox-3-1-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-1-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Care management and oversight because family is far away or overwhelmed\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-1-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Care management and oversight because family is far away or overwhelmed<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-2-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Help navigating complex family dynamics\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-2-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Help navigating complex family dynamics<\/span><\/label><label id=\"forminator-field-checkbox-3-3-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-3-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Health advocacy with physicians, hospital, or insurance agency\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Health-advocacy-with-physicians,-hospital,-or-insurance-agency\" id=\"forminator-field-checkbox-3-3-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-3-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Health advocacy with physicians, hospital, or insurance agency<\/span><\/label><label id=\"forminator-field-checkbox-3-4-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-4-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Coordination of health, legal, or financial planning\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Coordination-of-health,-legal,-or-financial-planning\" id=\"forminator-field-checkbox-3-4-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-4-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Coordination of health, legal, or financial planning<\/span><\/label><label id=\"forminator-field-checkbox-3-5-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-5-6a202c3f35103\" class=\"forminator-checkbox\" title=\"House management, help around the house, or coordinating repairs\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"House-management,-help-around-the-house,-or-coordinating-repairs\" id=\"forminator-field-checkbox-3-5-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-5-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">House management, help around the house, or coordinating repairs<\/span><\/label><label id=\"forminator-field-checkbox-3-6-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-6-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Assistance with finding and\/or moving to an ideal home or community\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Assistance-with-finding-and-or-moving-to-an-ideal-home-or-community\" id=\"forminator-field-checkbox-3-6-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-6-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Assistance with finding and\/or moving to an ideal home or community<\/span><\/label><label id=\"forminator-field-checkbox-3-7-6a202c3f35103-label\" for=\"forminator-field-checkbox-3-7-6a202c3f35103\" class=\"forminator-checkbox\" title=\"None\/other\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"None-other\" id=\"forminator-field-checkbox-3-7-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-3-7-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">None\/other<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-145--page-5\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-145--page-5-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"5\"\n\t\t\t\tdata-label=\"Page  5\"\n\t\t\t\tdata-actual-label=\"Page 6\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a202c3f35103-label\"><span id=\"forminator-radiogroup-radio-5-6a202c3f35103-label\" class=\"forminator-label\">Have you had home care from a professional caregiver before?<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a202c3f35103\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a202c3f35103\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a202c3f35103-label\"><span id=\"forminator-radiogroup-radio-6-6a202c3f35103-label\" class=\"forminator-label\">Is the care recipient open to receiving care or resistant?<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a202c3f35103\" class=\"forminator-radio\" title=\"Open\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Open<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a202c3f35103\" class=\"forminator-radio\" title=\"Resistant\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Resistant<\/span><\/label><label id=\"forminator-field-radio-6-label-3\" for=\"forminator-field-radio-6-3-6a202c3f35103\" class=\"forminator-radio\" title=\"Not sure\"><input type=\"radio\" name=\"radio-6\" value=\"Not-sure\" id=\"forminator-field-radio-6-3-6a202c3f35103\" aria-labelledby=\"forminator-field-radio-6-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not sure<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-6a202c3f35103-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-6a202c3f35103-label\" class=\"forminator-label\">How are you planning to pay for care?<\/span><label id=\"forminator-field-checkbox-4-1-6a202c3f35103-label\" for=\"forminator-field-checkbox-4-1-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Private pay\/out-of pocket\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-4-1-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Private pay\/out-of pocket<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6a202c3f35103-label\" for=\"forminator-field-checkbox-4-2-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Long-term care insurance\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-4-2-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Long-term care insurance<\/span><\/label><label id=\"forminator-field-checkbox-4-3-6a202c3f35103-label\" for=\"forminator-field-checkbox-4-3-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Medicare\/Medicaid\/Medicare Waiver\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Medicare-Medicaid-Medicare-Waiver\" id=\"forminator-field-checkbox-4-3-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-4-3-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Medicare\/Medicaid\/Medicare Waiver<\/span><\/label><label id=\"forminator-field-checkbox-4-4-6a202c3f35103-label\" for=\"forminator-field-checkbox-4-4-6a202c3f35103\" class=\"forminator-checkbox\" title=\"Not sure\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Not-sure\" id=\"forminator-field-checkbox-4-4-6a202c3f35103\" aria-labelledby=\"forminator-field-checkbox-4-4-6a202c3f35103-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Not sure<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a202c3f35103\" id=\"forminator-field-textarea-1_6a202c3f35103-label\" class=\"forminator-label\">What goals are you hoping to accomplish by setting up home care?<\/label><textarea name=\"textarea-1\" placeholder=\"E.g. text placeholder\nYou can add new lines\" id=\"forminator-field-textarea-1_6a202c3f35103\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_6a202c3f35103\" id=\"forminator-field-consent-1_6a202c3f35103-label\" class=\"forminator-label\">Consent <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6a202c3f35103__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6a202c3f35103\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6a202c3f35103-label\" aria-describedby=\"forminator-field-consent-1_6a202c3f35103__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6a202c3f35103__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>Yes, I agree with the <a rel=\"noopener\" target=\"_blank\" href=\"#\">privacy policy<\/a> and <a rel=\"noopener\" target=\"_blank\" href=\"#\">terms and conditions<\/a> which I have read on this website. I agree Proud, care and its affiliates, subsidiaries, and\/or agents may contact me via email, telephone, or text (Msg&amp;data rates may apply. Recurring msgs. Text STOP to cancel) via automatic telephone dialing system and\/or artificial or prerecorded voice, to arrange a free care consultation, as well as to provide me with general marketing communications. I understand I do not need to provide this consent to receive any good or service.<\/p><\/div><\/div><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Submit<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"4c91d85841\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/17\" \/><input type=\"hidden\" name=\"form_id\" value=\"145\"><input type=\"hidden\" name=\"page_id\" value=\"17\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/get-care\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-3cba6f15 e-con-full e-flex e-con e-child\" data-id=\"3cba6f15\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5a08f62b elementor-widget elementor-widget-heading\" data-id=\"5a08f62b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">What happens next?\n\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3d03756a elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"3d03756a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-check-circle\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 48c110.532 0 200 89.451 200 200 0 110.532-89.451 200-200 200-110.532 0-200-89.451-200-200 0-110.532 89.451-200 200-200m140.204 130.267l-22.536-22.718c-4.667-4.705-12.265-4.736-16.97-.068L215.346 303.697l-59.792-60.277c-4.667-4.705-12.265-4.736-16.97-.069l-22.719 22.536c-4.705 4.667-4.736 12.265-.068 16.971l90.781 91.516c4.667 4.705 12.265 4.736 16.97.068l172.589-171.204c4.704-4.668 4.734-12.266.067-16.971z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">A dedicated Emerest representative will contact you within 24 hours.<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-check-circle\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 48c110.532 0 200 89.451 200 200 0 110.532-89.451 200-200 200-110.532 0-200-89.451-200-200 0-110.532 89.451-200 200-200m140.204 130.267l-22.536-22.718c-4.667-4.705-12.265-4.736-16.97-.068L215.346 303.697l-59.792-60.277c-4.667-4.705-12.265-4.736-16.97-.069l-22.719 22.536c-4.705 4.667-4.736 12.265-.068 16.971l90.781 91.516c4.667 4.705 12.265 4.736 16.97.068l172.589-171.204c4.704-4.668 4.734-12.266.067-16.971z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">We will discuss your needs.<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-check-circle\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 48c110.532 0 200 89.451 200 200 0 110.532-89.451 200-200 200-110.532 0-200-89.451-200-200 0-110.532 89.451-200 200-200m140.204 130.267l-22.536-22.718c-4.667-4.705-12.265-4.736-16.97-.068L215.346 303.697l-59.792-60.277c-4.667-4.705-12.265-4.736-16.97-.069l-22.719 22.536c-4.705 4.667-4.736 12.265-.068 16.971l90.781 91.516c4.667 4.705 12.265 4.736 16.97.068l172.589-171.204c4.704-4.668 4.734-12.266.067-16.971z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">We will select the best options for you based on your needs.<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Request Care Help us understand your situation and current needs. Then we\u2019ll set up a free phone consultation so you can get the right support and care services to live well and age successfully at home. Note: This form is fully customizable and seamlessly integrates with major CRMs, Google Docs, and more for automated data [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-17","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/17","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/comments?post=17"}],"version-history":[{"count":5,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/17\/revisions"}],"predecessor-version":[{"id":153,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/17\/revisions\/153"}],"wp:attachment":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/media?parent=17"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}