{"id":783,"date":"2025-10-09T21:22:34","date_gmt":"2025-10-09T21:22:34","guid":{"rendered":"https:\/\/staidan.11-11marketing.ca\/?page_id=783"},"modified":"2025-10-10T16:10:49","modified_gmt":"2025-10-10T16:10:49","slug":"form-ng-paggamit-ng-referral-na-outreach-ng-nakatatanda","status":"publish","type":"page","link":"https:\/\/staidanssociety.ca\/tl\/seniors-outreach-referral-intake-form\/","title":{"rendered":"Form ng Referral at Pagkuha ng Seniors Outreach"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Referral Source Information<\/h3><\/div><div id=\"field_6_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_3'>Date of Referral:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_6_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_3' class='gform_hidden' value='https:\/\/staidanssociety.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_4\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_4'>Referral Source Name\/Agency:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_6_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_6_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_6\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_6'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_6_6' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Client Information<\/h3><\/div><div id=\"field_6_8\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Full Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_6_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_9\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_9'>Phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_6_9' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_10'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_6_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_11\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_11'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_6_11' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Postal Code:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you wish to be added to our distribution list?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_14'>\n\t\t\t<div class='gchoice gchoice_6_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_6_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_0' id='label_6_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_6_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_1' id='label_6_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Housing:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_15'><div class='gchoice gchoice_6_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Apartment'  id='choice_6_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>Apartment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='House'  id='choice_6_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_2' id='label_6_15_2' class='gform-field-label gform-field-label--type-inline'>House<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Other'  id='choice_6_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_3' id='label_6_15_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Own'  id='choice_6_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_4' id='label_6_15_4' class='gform-field-label gform-field-label--type-inline'>Own<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Rent'  id='choice_6_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_5' id='label_6_15_5' class='gform-field-label gform-field-label--type-inline'>Rent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.6' type='checkbox'  value='Subsidized'  id='choice_6_15_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_6' id='label_6_15_6' class='gform-field-label gform-field-label--type-inline'>Subsidized<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Current Living Arrangement:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_16'><div class='gchoice gchoice_6_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Alone'  id='choice_6_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_1' id='label_6_16_1' class='gform-field-label gform-field-label--type-inline'>Alone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Spouse'  id='choice_6_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_2' id='label_6_16_2' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Family'  id='choice_6_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_3' id='label_6_16_3' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Other'  id='choice_6_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_4' id='label_6_16_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender Identity:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_18'>\n\t\t\t<div class='gchoice gchoice_6_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Male'  id='choice_6_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_18_0' id='label_6_18_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Female'  id='choice_6_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_18_1' id='label_6_18_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Other'  id='choice_6_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_18_2' id='label_6_18_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_19'>Date of Birth:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_6_19' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_19' class='gform_hidden' value='https:\/\/staidanssociety.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>PHN #:<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_21'>SIN #:<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_6_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_22'>Family Physician (name and contact):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_6_22' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Green Sleeve:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_23'>\n\t\t\t<div class='gchoice gchoice_6_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_6_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_0' id='label_6_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_6_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_1' id='label_6_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_25\" class=\"gfield gfield--type-text gfield--input-type-text display-block field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_25'>Location:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_6_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vulnerable Person Registration:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_26'>\n\t\t\t<div class='gchoice gchoice_6_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_6_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_26_0' id='label_6_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_6_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_26_1' id='label_6_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Primary Contact (if applicable):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_6_27' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_28\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_28'>When is the best time of day to call?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_6_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can a message be left?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_29'>\n\t\t\t<div class='gchoice gchoice_6_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_6_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_0' id='label_6_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_6_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_1' id='label_6_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Unsure'  id='choice_6_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_2' id='label_6_29_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_30\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_30'>Primary Language:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_6_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_31\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_31'>Additional Languages:<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_6_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Equity Information (select all that apply):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_32'><div class='gchoice gchoice_6_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='First Nation'  id='choice_6_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_32_1' id='label_6_32_1' class='gform-field-label gform-field-label--type-inline'>First Nation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='Status'  id='choice_6_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_32_2' id='label_6_32_2' class='gform-field-label gform-field-label--type-inline'>Status<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='Non Status'  id='choice_6_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_32_3' id='label_6_32_3' class='gform-field-label gform-field-label--type-inline'>Non Status<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='Metis'  id='choice_6_32_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_32_4' id='label_6_32_4' class='gform-field-label gform-field-label--type-inline'>Metis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox status-member field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Status #:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_34'><div class='gchoice gchoice_6_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Member of Visible Minority'  id='choice_6_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_34_1' id='label_6_34_1' class='gform-field-label gform-field-label--type-inline'>Member of Visible Minority<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Newcomer'  id='choice_6_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_34_2' id='label_6_34_2' class='gform-field-label gform-field-label--type-inline'>Newcomer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Person with Disabilities'  id='choice_6_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_34_3' id='label_6_34_3' class='gform-field-label gform-field-label--type-inline'>Person with Disabilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Veteran'  id='choice_6_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_34_4' id='label_6_34_4' class='gform-field-label gform-field-label--type-inline'>Veteran<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_35'>Country of Origin:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_6_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client receiving Home Care Services?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_36'>\n\t\t\t<div class='gchoice gchoice_6_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_6_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_0' id='label_6_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_6_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_1' id='label_6_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_37\" class=\"gfield gfield--type-text gfield--input-type-text display-block field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'>Case Manager and Schedule (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_6_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client receiving support through Meals on Wheels?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_38'>\n\t\t\t<div class='gchoice gchoice_6_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_6_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_38_0' id='label_6_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_6_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_38_1' id='label_6_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_39\" class=\"gfield gfield--type-text gfield--input-type-text display-block field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_39'>Schedule (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_6_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_40'>Please list all current supports or services including agency\/professional supports or programs, family or friends. Include contact information:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_6_40' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"mb-10\">Finances<\/h3>\n<p>(This information is relevant to benefits and program eligibility.)<\/p><\/div><fieldset id=\"field_6_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Source of Income (if known):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_42'><div class='gchoice gchoice_6_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='CPP'  id='choice_6_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_1' id='label_6_42_1' class='gform-field-label gform-field-label--type-inline'>CPP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='OAS'  id='choice_6_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_2' id='label_6_42_2' class='gform-field-label gform-field-label--type-inline'>OAS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='GIS'  id='choice_6_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_3' id='label_6_42_3' class='gform-field-label gform-field-label--type-inline'>GIS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_42_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.4' type='checkbox'  value='ASB'  id='choice_6_42_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_4' id='label_6_42_4' class='gform-field-label gform-field-label--type-inline'>ASB<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_42_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.5' type='checkbox'  value='Work Pension'  id='choice_6_42_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_5' id='label_6_42_5' class='gform-field-label gform-field-label--type-inline'>Work Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_42_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.6' type='checkbox'  value='Other'  id='choice_6_42_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_6' id='label_6_42_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_43\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_43'>Annual Income (Line 15000):<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_6_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_44\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_44'>Income Tax Filed (list most current year):<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_6_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Reason for Referral<\/h3><\/div><fieldset id=\"field_6_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox blue-color-text field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reason for Referral<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_45'><div class='gchoice gchoice_6_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Financial (&lt;span&gt;financial assessment, assistance with applications, arears\/collections concerns, budgeting&lt;\/span&gt;)'  id='choice_6_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_1' id='label_6_45_1' class='gform-field-label gform-field-label--type-inline'>Financial (<span>financial assessment, assistance with applications, arears\/collections concerns, budgeting<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Transportation (&lt;span&gt;local, smart bus, conventional bus, Drive Happiness, out of town medical&lt;\/span&gt;)'  id='choice_6_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_2' id='label_6_45_2' class='gform-field-label gform-field-label--type-inline'>Transportation (<span>local, smart bus, conventional bus, Drive Happiness, out of town medical<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Health Supports (&lt;span&gt;medication or equipment fee coverage, referral, connection to health care professionals&lt;\/span&gt;)'  id='choice_6_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_3' id='label_6_45_3' class='gform-field-label gform-field-label--type-inline'>Health Supports (<span>medication or equipment fee coverage, referral, connection to health care professionals<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Housing (&lt;span&gt;Wood Buffalo Housing: Subsidized Seniors Housing, Rotary House, Seniors Independent Living, Willow Square, Arrears, or eviction and alternatives&lt;\/span&gt;)'  id='choice_6_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_4' id='label_6_45_4' class='gform-field-label gform-field-label--type-inline'>Housing (<span>Wood Buffalo Housing: Subsidized Seniors Housing, Rotary House, Seniors Independent Living, Willow Square, Arrears, or eviction and alternatives<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='Resources and Referrals (&lt;span&gt;connection to funding, programming, counselling, food, clothing, legal supports&lt;\/span&gt;)'  id='choice_6_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_5' id='label_6_45_5' class='gform-field-label gform-field-label--type-inline'>Resources and Referrals (<span>connection to funding, programming, counselling, food, clothing, legal supports<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.6' type='checkbox'  value='Social Supports (&lt;span&gt;seniors programming due to loneliness and isolation, wellness sessions, distribution list&lt;\/span&gt;)'  id='choice_6_45_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_6' id='label_6_45_6' class='gform-field-label gform-field-label--type-inline'>Social Supports (<span>seniors programming due to loneliness and isolation, wellness sessions, distribution list<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.7' type='checkbox'  value='Outreach (&lt;span&gt;accompaniment needed to access support services&lt;\/span&gt;)'  id='choice_6_45_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_7' id='label_6_45_7' class='gform-field-label gform-field-label--type-inline'>Outreach (<span>accompaniment needed to access support services<\/span>)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.8' type='checkbox'  value='Elder Abuse\/Mistreatment (&lt;span&gt;financial, emotional, physical, sexual, neglect)'  id='choice_6_45_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_8' id='label_6_45_8' class='gform-field-label gform-field-label--type-inline'>Elder Abuse\/Mistreatment (<span>financial, emotional, physical, sexual, neglect)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.9' type='checkbox'  value='Unsure of Specific Need'  id='choice_6_45_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_9' id='label_6_45_9' class='gform-field-label gform-field-label--type-inline'>Unsure of Specific Need<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_45_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.11' type='checkbox'  value='Concerned About In-Home Supports (&lt;span&gt;&lt;strong&gt;please complete AWAH Supports Referral below,&lt;\/strong&gt;&lt;\/span&gt; 60+ only)'  id='choice_6_45_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_11' id='label_6_45_11' class='gform-field-label gform-field-label--type-inline'>Concerned About In-Home Supports (<span><strong>please complete AWAH Supports Referral below,<\/strong><\/span> 60+ only)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client aware of this referral?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_47'>\n\t\t\t<div class='gchoice gchoice_6_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_6_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_0' id='label_6_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_6_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_1' id='label_6_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does the client consent to sharing relevant health information?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_48'>\n\t\t\t<div class='gchoice gchoice_6_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_6_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_0' id='label_6_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_6_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_1' id='label_6_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_49'>Client Hospitalization Discharge Date (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_6_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_50'>Additional Comments\/Concerns:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_6_50' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Age Well At Home (AWAH) Support Services Referral (60+)<\/h3><\/div><div id=\"field_6_52\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_52'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_6_52' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_52_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_52' class='gform_hidden' value='https:\/\/staidanssociety.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox strong column mb-20 field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Services<\/legend><div class='gfield_description' id='gfield_description_6_54'><p>Age Well At Home (AWAH) Support Services help adults aged 60+ live independently at home by offering services such as cleaning, laundry, and meals.  <strong>Individual needs are assessed with each client, and costs are income-based and discussed personally. <\/strong><\/p><\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_54'><div class='gchoice gchoice_6_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Home Supports (house cleaning\/maintenance, laundry, shopping\/food preparation, organization, minor home maintenance)'  id='choice_6_54_1'   aria-describedby=\"gfield_description_6_54\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_6_54_1' id='label_6_54_1' class='gform-field-label gform-field-label--type-inline'>Home Supports (house cleaning\/maintenance, laundry, shopping\/food preparation, organization, minor home maintenance)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Snow Removal'  id='choice_6_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_54_2' id='label_6_54_2' class='gform-field-label gform-field-label--type-inline'>Snow Removal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_54_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.3' type='checkbox'  value='Lawn Care'  id='choice_6_54_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_54_3' id='label_6_54_3' class='gform-field-label gform-field-label--type-inline'>Lawn Care<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio strong field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Letter<\/legend><div class='gfield_description' id='gfield_description_6_55'>The client being referred is physically unable to maintain their home. I am willing to provide a letter to allow them to access financial support from the Alberta Seniors Benefits Special Needs Program.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_55'>\n\t\t\t<div class='gchoice gchoice_6_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_6_55_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_6_55\"   \/>\n\t\t\t\t\t<label for='choice_6_55_0' id='label_6_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_6_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_56\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload display-block field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_56'>Please attach lettter, if applicable.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='33554432' \/><input name='input_56' id='input_6_56' type='file' class='large' aria-describedby=\"gfield_upload_rules_6_56\" onchange='javascript:gformValidateFileSize( this, 33554432 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_56'>Max. file size: 32 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_56'><\/div> <\/div><\/div><div id=\"field_6_57\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_57'>Risks for Support Workers (mental instability, addiction, physical aggression, others in the home, animals):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_6_57' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_58\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"mb-10\">Additional Information &#8211; St. Aidan&#8217;s Society Internal Use Only<\/h3>\n<p class=\"orange\">Completing this section helps our Link Workers and Outreach Team provide better support and identify how to best meet clients\u2019 needs.<\/p><\/div><fieldset id=\"field_6_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been involved with St. Aidan\u2019s Society?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_59'>\n\t\t\t<div class='gchoice gchoice_6_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_6_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_59_0' id='label_6_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_6_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_59_1' id='label_6_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio flex-row field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How did you hear about us?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_60'>\n\t\t\t<div class='gchoice gchoice_6_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Professional'  id='choice_6_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_0' id='label_6_60_0' class='gform-field-label gform-field-label--type-inline'>Professional<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Family\/Friend'  id='choice_6_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_1' id='label_6_60_1' class='gform-field-label gform-field-label--type-inline'>Family\/Friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Social Media'  id='choice_6_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_2' id='label_6_60_2' class='gform-field-label gform-field-label--type-inline'>Social Media<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Website'  id='choice_6_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_3' id='label_6_60_3' class='gform-field-label gform-field-label--type-inline'>Website<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Other'  id='choice_6_60_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_4' id='label_6_60_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox strong field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mistreated<\/legend><div class='gfield_description' id='gfield_description_6_61'>Mistreatment of older adults can occur, and help is available. We ask all program users: Have you experienced or are you currently experiencing any form of mistreatment?<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_61'><div class='gchoice gchoice_6_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Financial'  id='choice_6_61_1'   aria-describedby=\"gfield_description_6_61\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_1' id='label_6_61_1' class='gform-field-label gform-field-label--type-inline'>Financial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Emotional'  id='choice_6_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_2' id='label_6_61_2' class='gform-field-label gform-field-label--type-inline'>Emotional<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Physical'  id='choice_6_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_3' id='label_6_61_3' class='gform-field-label gform-field-label--type-inline'>Physical<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Sexual'  id='choice_6_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_4' id='label_6_61_4' class='gform-field-label gform-field-label--type-inline'>Sexual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Neglect'  id='choice_6_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_5' id='label_6_61_5' class='gform-field-label gform-field-label--type-inline'>Neglect<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_62\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_62'>Details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_6_62' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_63\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_63'>How are you with technology (smart phone, computer, tablet, internet, email) and what is your level of proficiency (can you create and reply to emails, retrieve voicemails)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_6_63' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Challenges with Mental Health or Addiction (current or historical):<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_64'>\n\t\t\t<div class='gchoice gchoice_6_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_6_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_64_0' id='label_6_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_6_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_64_1' id='label_6_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_65\" class=\"gfield gfield--type-textarea gfield--input-type-textarea display-block field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_65'>Details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_6_65' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is Life Skills Support needed (budgeting, bill payments, cooking, cleaning)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_66'>\n\t\t\t<div class='gchoice gchoice_6_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_6_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_66_0' id='label_6_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_6_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_66_1' id='label_6_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_67\" class=\"gfield gfield--type-textarea gfield--input-type-textarea display-block field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_67'>Details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_67' id='input_6_67' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_68\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_68'>Notes\/Concerns:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_6_68' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <div 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