<div class=”row clearfix”>
<div class=”col-md-8 offset-md-2 pt-3″>
<div class=”form-group”>
<label>Your full name:</label>
[text* your-full-name class:form-control]
</div>
<div class=”form-group”>
<label>What’s the zip code of the person who needs care?</label>
[text* zip-code class:form-control]
</div>
<div class=”form-group”>
<label>Who needs care or help at home?</label>
[select* class:form-select who-needs-care class:form-select include_blank “A loved one” “Myself” “A client” “Other”]
</div>
<p> </p>
<div class=”form-group”>
<label>What is the care recipient’s first name?</label>
[text* care-recipient-first-name class:form-control]
</div>
<div class=”form-group”>
<label>What is the care recipient’s last name?</label>
[text* care-recipient-last-name class:form-control]
</div>
<div class=”form-group”>
<label>When do you need to start care?</label>
[select* start-care class:form-select include_blank “Immediately” “In the Coming Weeks” “Planning for the Future” “Not Sure”]
</div>
<p> </p>
<div class=”form-group”>
<label>Do you know how much care you’ll need?</label>
[select* care-amount class:form-select include_blank “A few hours a day” “Most of the day” “Around the clock support” “Not sure”]
</div>
<p> </p>
<div class=”form-group”>
<label>Are you planning for long-term care?</label>
[select* long-term-care class:form-select include_blank “No, just a few weeks.” “Yes, we need a long-term solution.” “Not sure”]
</div>
<p> </p>
<div class=”form-group”>
<label>Can you give us more details on the care you’ll need?</label>
[checkbox personal-care “Personal Care (Help with Bathing, Grooming, Dressing, etc.)”]
[checkbox supportive-care “Supportive Care Within the Home (Meal Preparation, Companionship, etc)”]
[checkbox lifestyle-support “Lifestyle Support (Help with Planning and Scheduling Social Events and Activities)”]
[checkbox transportation “Transportation (Shopping, Errands, Medical Appointments, Social Events)”]
[checkbox memory-care-diagnosis “Memory Care with a Diagnosis (Alzheimer’s or Other Type of Dementia)”]
[checkbox memory-care-no-diagnosis “Memory Care Without a Diagnosis (Confusion, Cognitive Decline, Memory Problems)”]
[checkbox mobility-support “Mobility Support (Getting Out of Bed, Bathroom, Walking)”]
[checkbox total-body-support “Total Body, Chairbound and Bedbound Support”]
[checkbox companionship “Companionship, Social Engagement, and Cognitive Stimulation”]
[checkbox coordination-oversight “Coordination and oversight of overall wellness”]
[checkbox safety-observation “Safety Observation or Wellness Checks”]
[checkbox medication-monitoring “Medication Monitoring or Management”]
[checkbox none-other “None/Other”]
</div>
<div class=”form-group”>
<label>Do you need any additional services?</label>
[checkbox care-management “Care Management and Oversight Because Family is Far Away or Overwhelmed”]
[checkbox family-dynamics “Help Navigating Complex Family Dynamics”]
[checkbox health-advocacy “Health Advocacy with Physicians, Hospital, or Insurance Agency”]
[checkbox coordination-planning “Coordination of Health, Legal, or Financial Planning”]
[checkbox house-management “House Management, Help Around the House, or Coordinating Repairs”]
[checkbox assistance-finding-home “Assistance With Finding and/or Moving to an Ideal Home or Community”]
[checkbox none-other-services “None/Other”]
</div>
<div class=”form-group”>
<label>Have you had home care from a professional caregiver before?</label>
[select* previous-care class:form-control include_blank “Yes” “No”]
</div>
<p> </p>
<div class=”form-group”>
<label>Is the care recipient open to receiving care or resistant?</label>
[select* care-recipient-openness class:form-control include_blank “Open” “Resistant” “Not Sure”]
</div>
<p> </p>
<div class=”form-group”>
<label>How are you planning to pay for care?</label>
[select* payment-method class:form-control include_blank “Private pay/out of pocket” “Long-term care insurance” “Medicare/Medicaid/Medicare Waiver” “Not sure”]
</div>
<p> </p>
<div class=”form-group”>
<label>What goals are you hoping to accomplish by setting up home care?</label>
[textarea your-goals class:form-control]
</div>
<h5>Please provide your contact information and hit submit. We’ll call you within 24 hours to set up your free phone consultation and email a summary of your care needs.</h5>
<div class=”form-group”>
<label>Phone:</label>
[tel* phone class:form-control]
</div>
<div class=”form-group”>
<label>Email:</label>
[email* your-email class:form-control]
</div>
<div class=”form-group text-center mb-3″>
[submit class:btn class:btn-primary class:btn-lg “Submit”]
</div>
</div>
</div>