{"id":5928,"date":"2026-01-08T08:04:38","date_gmt":"2026-01-08T08:04:38","guid":{"rendered":"https:\/\/www.goharmonyhouse.com\/?page_id=5928"},"modified":"2026-01-08T08:17:00","modified_gmt":"2026-01-08T08:17:00","slug":"supportive-housing-client-intake-form","status":"publish","type":"page","link":"https:\/\/www.goharmonyhouse.com\/index.php\/supportive-housing-client-intake-form\/","title":{"rendered":"Supportive Housing Client Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5928\" class=\"elementor elementor-5928\" data-elementor-post-type=\"page\">\n\t\t\t\t        <section class=\"elementor-section elementor-top-section elementor-element elementor-element-7a112bf elementor-section-stretched elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default ct-header-fixed-none ct-row-max-none\" data-id=\"7a112bf\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n                            <div class=\"elementor-background-overlay\"><\/div>\n                \n                        <div class=\"elementor-container elementor-column-gap-extended \">\n                    <div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f50c66e\" data-id=\"f50c66e\" data-element_type=\"column\">\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\n                    \n                <section class=\"elementor-section elementor-inner-section elementor-element elementor-element-20d0655 elementor-section-boxed elementor-section-height-default elementor-section-height-default ct-header-fixed-none ct-row-max-none\" data-id=\"20d0655\" data-element_type=\"section\">\n            \n                        <div class=\"elementor-container elementor-column-gap-narrow \">\n                    <div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-abcc96f\" data-id=\"abcc96f\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\n                    \n        \t\t<div class=\"elementor-element elementor-element-2908354 elementor-invisible elementor-widget elementor-widget-ct_heading\" data-id=\"2908354\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"ct_heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ct-heading h-align-center  sub-style1 ct-heading-left item-st-line-bottom1\">\r\n\t    <h3 class=\"item--title st-line-bottom1 \" data-wow-delay=\"ms\">\r\n                <span class=\"sp-main\">\r\n            \r\n            Supportive Housing Client Intake Form\n\r\n            \r\n                    <\/span>\r\n                    <div class=\"ct-heading-divider\"><span><\/span><\/div>\r\n            <\/h3>\r\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cdcfac9 elementor-widget elementor-widget-shortcode\" data-id=\"cdcfac9\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-5927 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-5927\" data-uid=\"69e09aab1d1b3\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-5927\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-5927 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"5927\"\r\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"69e09aab1d1b3\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e09aab1d1b3\" id=\"forminator-field-date-1-picker_69e09aab1d1b3-label\" class=\"forminator-label\">Date of Intake <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69e09aab1d1b3\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e09aab1d1b3\" id=\"forminator-field-name-2_69e09aab1d1b3-label\" class=\"forminator-label\">Full Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69e09aab1d1b3\" id=\"forminator-field-date-2-picker_69e09aab1d1b3-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69e09aab1d1b3\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69e09aab1d1b3\" id=\"forminator-field-number-1_69e09aab1d1b3-label\" class=\"forminator-label\">Age<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69e09aab1d1b3\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/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_69e09aab1d1b3\" id=\"forminator-field-text-1_69e09aab1d1b3-label\" class=\"forminator-label\">Social Security Number (Last 4 digits)<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e09aab1d1b3\" id=\"forminator-field-phone-1_69e09aab1d1b3-label\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69e09aab1d1b3\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e09aab1d1b3\" id=\"forminator-field-email-1_69e09aab1d1b3-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69e09aab1d1b3\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><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-1-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69e09aab1d1b3-label\" class=\"forminator-label\">Gender<\/span><label id=\"forminator-field-checkbox-1-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-1-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Male\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-1-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Male<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-1-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Female\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-1-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Female<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-1-3-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Non-binary\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Non-binary\" id=\"forminator-field-checkbox-1-3-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-1-3-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non-binary<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-1-4-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Prefer not to say\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Prefer-not-to-say\" id=\"forminator-field-checkbox-1-4-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-1-4-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Prefer not to say<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69e09aab1d1b3\" id=\"forminator-field-name-3_69e09aab1d1b3-label\" class=\"forminator-label\">Emergency Contact Name<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69e09aab1d1b3\" id=\"forminator-field-text-2_69e09aab1d1b3-label\" class=\"forminator-label\">Relationship<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e09aab1d1b3\" id=\"forminator-field-phone-2_69e09aab1d1b3-label\" class=\"forminator-label\">Emergency Contact Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_69e09aab1d1b3\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Current Living Situation<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-69e09aab1d1b3-label\"><label id=\"forminator-field-checkbox-2-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-2-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Homeless\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-2-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Homeless<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-2-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Couchsurfing \/ Staying with others\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-2-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Couchsurfing \/ Staying with others<\/span><\/label><label id=\"forminator-field-checkbox-2-3-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-2-3-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Transitional Housing\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Transitional-Housing\" id=\"forminator-field-checkbox-2-3-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-2-3-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Transitional Housing<\/span><\/label><label id=\"forminator-field-checkbox-2-4-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-2-4-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Jail\/Prison Release\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Jail-Prison-Release\" id=\"forminator-field-checkbox-2-4-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-2-4-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Jail\/Prison Release<\/span><\/label><label id=\"forminator-field-checkbox-2-5-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-2-5-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Hospital \/ Rehab\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Hospital---Rehab\" id=\"forminator-field-checkbox-2-5-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-2-5-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hospital \/ Rehab<\/span><\/label><label id=\"forminator-field-checkbox-2-6-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-2-6-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Other\" id=\"forminator-field-checkbox-2-6-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-2-6-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Referral Source (If Applicable)<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-69e09aab1d1b3-label\"><label id=\"forminator-field-checkbox-3-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Self\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Self<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Agency\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Agency<\/span><\/label><label id=\"forminator-field-checkbox-3-3-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-3-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Parole\/Probation\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Parole-Probation\" id=\"forminator-field-checkbox-3-3-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-3-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Parole\/Probation<\/span><\/label><label id=\"forminator-field-checkbox-3-4-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-4-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Hospital or Treatment Center\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Hospital-or-Treatment-Center\" id=\"forminator-field-checkbox-3-4-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-4-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hospital or Treatment Center<\/span><\/label><label id=\"forminator-field-checkbox-3-5-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-5-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Family\/Friend\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Family-Friend\" id=\"forminator-field-checkbox-3-5-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-5-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Family\/Friend<\/span><\/label><label id=\"forminator-field-checkbox-3-6-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-6-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Referring Contact Name\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Referring-Contact-Name\" id=\"forminator-field-checkbox-3-6-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-6-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Referring Contact Name<\/span><\/label><label id=\"forminator-field-checkbox-3-7-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-3-7-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Phone\/Email\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Phone-Email\" id=\"forminator-field-checkbox-3-7-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-3-7-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Phone\/Email<\/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_69e09aab1d1b3\" id=\"forminator-field-textarea-1_69e09aab1d1b3-label\" class=\"forminator-label\">Brief Summary of Situation \/ Reason for Housing Need<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69e09aab1d1b3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e09aab1d1b3\" id=\"forminator-field-text-3_69e09aab1d1b3-label\" class=\"forminator-label\">Medical &amp; Mental Health History (List Below)<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Mental health diagnosis (if any)<\/h2><\/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-4-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-69e09aab1d1b3-label\" class=\"forminator-label\">Substance use history (if any)<\/span><label id=\"forminator-field-checkbox-4-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-4-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Alcohol\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-4-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Alcohol<\/span><\/label><label id=\"forminator-field-checkbox-4-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-4-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Drugs\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-4-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Drugs<\/span><\/label><label id=\"forminator-field-checkbox-4-3-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-4-3-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"None\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"None\" id=\"forminator-field-checkbox-4-3-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-4-3-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">None<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69e09aab1d1b3\" id=\"forminator-field-text-4_69e09aab1d1b3-label\" class=\"forminator-label\">If yes, explain<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Legal Background<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-5\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-5-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5-69e09aab1d1b3-label\" class=\"forminator-label\">Are you currently on parole or probation? (List PO Name\/Phone Number)<\/span><label id=\"forminator-field-checkbox-5-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-5-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"one\" id=\"forminator-field-checkbox-5-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-5-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-5-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-5-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"two\" id=\"forminator-field-checkbox-5-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-5-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-69e09aab1d1b3-label\" class=\"forminator-label\">Are you a registered sex offender?<\/span><label id=\"forminator-field-checkbox-6-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-6-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"one\" id=\"forminator-field-checkbox-6-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-6-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-6-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-6-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"two\" id=\"forminator-field-checkbox-6-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-6-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Income Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-7\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-7-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-7-69e09aab1d1b3-label\" class=\"forminator-label\">Do you have a source of income?<\/span><label id=\"forminator-field-checkbox-7-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-7-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"one\" id=\"forminator-field-checkbox-7-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-7-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-7-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-7-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"two\" id=\"forminator-field-checkbox-7-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-7-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><label id=\"forminator-field-checkbox-7-3-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-7-3-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"SSI\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"SSI\" id=\"forminator-field-checkbox-7-3-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-7-3-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">SSI<\/span><\/label><label id=\"forminator-field-checkbox-7-4-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-7-4-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"SSDI\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"SSDI\" id=\"forminator-field-checkbox-7-4-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-7-4-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">SSDI<\/span><\/label><label id=\"forminator-field-checkbox-7-5-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-7-5-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Employment\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"Employment\" id=\"forminator-field-checkbox-7-5-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-7-5-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Employment<\/span><\/label><label id=\"forminator-field-checkbox-7-6-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-7-6-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"Other\" id=\"forminator-field-checkbox-7-6-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-7-6-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69e09aab1d1b3\" id=\"forminator-field-text-5_69e09aab1d1b3-label\" class=\"forminator-label\">Monthly Income Amount (if any)<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"$\" id=\"forminator-field-text-5_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Housing Preferences or Needs<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-8\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-8-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-8-69e09aab1d1b3-label\" class=\"forminator-label\">Any disabilities or accommodations needed?<\/span><label id=\"forminator-field-checkbox-8-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-8-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"one\" id=\"forminator-field-checkbox-8-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-8-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-8-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-8-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"two\" id=\"forminator-field-checkbox-8-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-8-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69e09aab1d1b3\" id=\"forminator-field-text-6_69e09aab1d1b3-label\" class=\"forminator-label\">If yes, explain<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-9\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-69e09aab1d1b3-label\" class=\"forminator-label\">Preferred Room Type<\/span><label id=\"forminator-field-checkbox-9-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-9-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Shared Room\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"one\" id=\"forminator-field-checkbox-9-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-9-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Shared Room<\/span><\/label><label id=\"forminator-field-checkbox-9-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-9-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Private Room (if available)\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"two\" id=\"forminator-field-checkbox-9-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-9-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Private Room (if available)<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Independent Living &amp; Functionality Acknowledgment<\/h2><h3 class=\"forminator-subtitle\">Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision.<\/h3><\/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-1-69e09aab1d1b3-label\"><span id=\"forminator-radiogroup-radio-1-69e09aab1d1b3-label\" class=\"forminator-label\">You must be able to manage your own:<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e09aab1d1b3\" class=\"forminator-radio\" title=\"Personal hygiene and grooming\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69e09aab1d1b3\" 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\">Personal hygiene and grooming<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e09aab1d1b3\" class=\"forminator-radio\" title=\"Meal preparation and eating\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e09aab1d1b3\" 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\">Meal preparation and eating<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-69e09aab1d1b3\" class=\"forminator-radio\" title=\"Medication (unless managed by an outside provider)\"><input type=\"radio\" name=\"radio-1\" value=\"Medication-(unless-managed-by-an-outside-provider)\" id=\"forminator-field-radio-1-3-69e09aab1d1b3\" 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\">Medication (unless managed by an outside provider)<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-69e09aab1d1b3\" class=\"forminator-radio\" title=\"Mobility and transportation arrangements\"><input type=\"radio\" name=\"radio-1\" value=\"Mobility-and-transportation-arrangements\" id=\"forminator-field-radio-1-4-69e09aab1d1b3\" 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\">Mobility and transportation arrangements<\/span><\/label><label id=\"forminator-field-radio-1-label-5\" for=\"forminator-field-radio-1-5-69e09aab1d1b3\" class=\"forminator-radio\" title=\"Housekeeping and laundry\"><input type=\"radio\" name=\"radio-1\" value=\"Housekeeping-and-laundry\" id=\"forminator-field-radio-1-5-69e09aab1d1b3\" aria-labelledby=\"forminator-field-radio-1-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Housekeeping and laundry<\/span><\/label><label id=\"forminator-field-radio-1-label-6\" for=\"forminator-field-radio-1-6-69e09aab1d1b3\" class=\"forminator-radio\" title=\"Daily living responsibilities\"><input type=\"radio\" name=\"radio-1\" value=\"Daily-living-responsibilities\" id=\"forminator-field-radio-1-6-69e09aab1d1b3\" aria-labelledby=\"forminator-field-radio-1-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Daily living responsibilities<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-10\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-10-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-10-69e09aab1d1b3-label\" class=\"forminator-label\">Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?<\/span><label id=\"forminator-field-checkbox-10-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-10-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"one\" id=\"forminator-field-checkbox-10-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-10-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-10-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-10-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"two\" id=\"forminator-field-checkbox-10-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-10-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69e09aab1d1b3\" id=\"forminator-field-text-7_69e09aab1d1b3-label\" class=\"forminator-label\">If No \u2013 Please explain<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-11\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-11-69e09aab1d1b3-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-11-69e09aab1d1b3-label\" class=\"forminator-label\">Do you currently have or need a home health care provider or outside support service?<\/span><label id=\"forminator-field-checkbox-11-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-11-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"Yes\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"one\" id=\"forminator-field-checkbox-11-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-11-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yes<\/span><\/label><label id=\"forminator-field-checkbox-11-2-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-11-2-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"two\" id=\"forminator-field-checkbox-11-2-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-11-2-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69e09aab1d1b3\" id=\"forminator-field-text-8_69e09aab1d1b3-label\" class=\"forminator-label\">If Yes \u2013 Agency Name (if applicable)<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-12\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-12-69e09aab1d1b3-label\"><label id=\"forminator-field-checkbox-12-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-12-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"one\" id=\"forminator-field-checkbox-12-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-12-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69e09aab1d1b3\" id=\"forminator-field-text-9_69e09aab1d1b3-label\" class=\"forminator-label\">Participant Initials<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69e09aab1d1b3\" id=\"forminator-field-date-3-picker_69e09aab1d1b3-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_69e09aab1d1b3\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-9\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Program Agreement Preview<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-13\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-13-69e09aab1d1b3-label\"><label id=\"forminator-field-checkbox-13-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-13-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"one\" id=\"forminator-field-checkbox-13-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-13-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-14\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-14-69e09aab1d1b3-label\"><label id=\"forminator-field-checkbox-14-1-69e09aab1d1b3-label\" for=\"forminator-field-checkbox-14-1-69e09aab1d1b3\" class=\"forminator-checkbox\" title=\"I acknowledge that violating rules may result in a strike or dismissal from the program.\"><input type=\"checkbox\" name=\"checkbox-14[]\" value=\"one\" id=\"forminator-field-checkbox-14-1-69e09aab1d1b3\" aria-labelledby=\"forminator-field-checkbox-14-1-69e09aab1d1b3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I acknowledge that violating rules may result in a strike or dismissal from the program.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-10\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Applicant Declaration<\/h2><h3 class=\"forminator-subtitle\">I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69e09aab1d1b3\" id=\"forminator-field-name-4_69e09aab1d1b3-label\" class=\"forminator-label\">Participant Name<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_69e09aab1d1b3\" id=\"forminator-field-text-10_69e09aab1d1b3-label\" class=\"forminator-label\">Participant Signature<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69e09aab1d1b3\" id=\"forminator-field-date-4-picker_69e09aab1d1b3-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_69e09aab1d1b3\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69e09aab1d1b3\" id=\"forminator-field-name-5_69e09aab1d1b3-label\" class=\"forminator-label\">Staff Name<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_69e09aab1d1b3\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature69e09aab20207\" id=\"forminator-field-ctlSignature69e09aab20207-label\" class=\"forminator-label\">Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature69e09aab20207_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature69e09aab20207_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69e09aab20207\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"69e09aab20207\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69e09aab1d1b3\" id=\"forminator-field-date-5-picker_69e09aab1d1b3-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-5-picker_69e09aab1d1b3\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"9ae8bdc974\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/5928\" \/><input type=\"hidden\" name=\"form_id\" value=\"5927\"><input type=\"hidden\" name=\"page_id\" value=\"5928\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/www.goharmonyhouse.com\/index.php\/supportive-housing-client-intake-form\/\"><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>\n        <\/div>\n                    <\/div>\n        <\/section>\n                    <\/div>\n        <\/div>\n                    <\/div>\n        <\/section>\n        \t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Supportive Housing Client Intake Form<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-5928","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/pages\/5928","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/comments?post=5928"}],"version-history":[{"count":7,"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/pages\/5928\/revisions"}],"predecessor-version":[{"id":5936,"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/pages\/5928\/revisions\/5936"}],"wp:attachment":[{"href":"https:\/\/www.goharmonyhouse.com\/index.php\/wp-json\/wp\/v2\/media?parent=5928"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}