{"id":657,"date":"2025-01-08T07:10:26","date_gmt":"2025-01-08T07:10:26","guid":{"rendered":"https:\/\/girdelight.com\/hala\/?page_id=657"},"modified":"2025-01-10T02:55:45","modified_gmt":"2025-01-10T02:55:45","slug":"intake-form-2","status":"publish","type":"page","link":"https:\/\/girdelight.com\/hala\/intake-form-2\/","title":{"rendered":"Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"657\" class=\"elementor elementor-657\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-789a2e6 e-flex e-con-boxed e-con e-parent\" data-id=\"789a2e6\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-96b5cc4 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-text-editor\" data-id=\"96b5cc4\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-754f5d9 e-flex e-con-boxed e-con e-parent\" data-id=\"754f5d9\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-947a1eb exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-spacer\" data-id=\"947a1eb\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7f33c71 e-flex e-con-boxed e-con e-parent\" data-id=\"7f33c71\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-cdd9340 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-heading\" data-id=\"cdd9340\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Participant Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0f2b109 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-spacer\" data-id=\"0f2b109\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c73adf3 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-wpforms\" data-id=\"c73adf3\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-border-style: solid;\n--wpforms-field-border-size: 1px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-border-color-spare: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-field-menu-color: #ffffff;\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-border-style: none;\n--wpforms-button-border-size: 1px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-border-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-page-break-color: #066aab;\n--wpforms-background-image: none;\n--wpforms-background-position: center center;\n--wpforms-background-repeat: no-repeat;\n--wpforms-background-size: cover;\n--wpforms-background-width: 100px;\n--wpforms-background-height: 100px;\n--wpforms-background-color: rgba( 0, 0, 0, 0 );\n--wpforms-background-url: none;\n--wpforms-container-padding: 0px;\n--wpforms-container-border-style: none;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-color: #000000;\n--wpforms-container-border-radius: 3px;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-elementor-widget-c73adf3\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-c73adf3 {\n\t\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-15d7a52e-29de-401c-b465-cfa56965266a wpforms-render-modern\" id=\"wpforms-649\"><form id=\"wpforms-form-649\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"649\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/hala\/wp-json\/wp\/v2\/pages\/657\" data-token=\"c9926ae86520f02c8d7e4f2ff358d293\" data-token-time=\"1781407603\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-649-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">What services you require from us?<\/legend><ul id=\"wpforms-649-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Short Term Accomodation (SIL)\" aria-errormessage=\"wpforms-649-field_8_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_8_1\">Short Term Accomodation (SIL)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_8_2\" name=\"wpforms[fields][8][]\" value=\"Personal care \/ Support worker\" aria-errormessage=\"wpforms-649-field_8_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_8_2\">Personal care \/ Support worker<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_8_3\" name=\"wpforms[fields][8][]\" value=\"Nursing services\" aria-errormessage=\"wpforms-649-field_8_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_8_3\">Nursing services<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_8_4\" name=\"wpforms[fields][8][]\" value=\"Travel \/ Transport\" aria-errormessage=\"wpforms-649-field_8_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_8_4\">Travel \/ Transport<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_8_5\" name=\"wpforms[fields][8][]\" value=\"Household task \/ Gardening\" aria-errormessage=\"wpforms-649-field_8_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_8_5\">Household task \/ Gardening<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_8_6\" name=\"wpforms[fields][8][]\" value=\"Community Participation\" aria-errormessage=\"wpforms-649-field_8_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_8_6\">Community Participation<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_9\">Date<\/label><input type=\"text\" id=\"wpforms-649-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-649-field_9-error\" ><\/div><div id=\"wpforms-649-field_11-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_11\">Date of Birth<\/label><input type=\"text\" id=\"wpforms-649-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-649-field_11-error\" ><\/div><div id=\"wpforms-649-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-649-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-649-field_1-error\" required><label for=\"wpforms-649-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-649-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-649-field_1-last-error\" required><label for=\"wpforms-649-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-649-field_13-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">Gender<\/legend><ul id=\"wpforms-649-field_13\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_13_1\" name=\"wpforms[fields][13]\" value=\"Male\" aria-errormessage=\"wpforms-649-field_13_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_13_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_13_2\" name=\"wpforms[fields][13]\" value=\"Female\" aria-errormessage=\"wpforms-649-field_13_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_13_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_13_3\" name=\"wpforms[fields][13]\" value=\"Transgender\" aria-errormessage=\"wpforms-649-field_13_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_13_3\">Transgender<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_13_4\" name=\"wpforms[fields][13]\" value=\"Intersex\" aria-errormessage=\"wpforms-649-field_13_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_13_4\">Intersex<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_13_5\" name=\"wpforms[fields][13]\" value=\"Prefer not to say\" aria-errormessage=\"wpforms-649-field_13_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_13_5\">Prefer not to say<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_14\">Phone Number<\/label><input type=\"text\" id=\"wpforms-649-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-649-field_14-error\" ><\/div><div id=\"wpforms-649-field_7-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_7\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-649-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" aria-errormessage=\"wpforms-649-field_7-error\" required><\/div><div id=\"wpforms-649-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_15\">Language spoken at home <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-649-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-649-field_15-error\" required><\/div><div id=\"wpforms-649-field_2-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Interpreter required<\/legend><ul id=\"wpforms-649-field_2\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_2_1\" name=\"wpforms[fields][2]\" value=\"Yes\" aria-errormessage=\"wpforms-649-field_2_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_2_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_2_2\" name=\"wpforms[fields][2]\" value=\"No\" aria-errormessage=\"wpforms-649-field_2_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_2_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_2_3\" name=\"wpforms[fields][2]\" value=\"Not sure\" aria-errormessage=\"wpforms-649-field_2_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_2_3\">Not sure<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Preferred option for communication<\/legend><ul id=\"wpforms-649-field_5\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_5_1\" name=\"wpforms[fields][5]\" value=\"Email\" aria-errormessage=\"wpforms-649-field_5_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_5_1\">Email<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_5_2\" name=\"wpforms[fields][5]\" value=\"Post\" aria-errormessage=\"wpforms-649-field_5_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_5_2\">Post<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_5_3\" name=\"wpforms[fields][5]\" value=\"Phone\" aria-errormessage=\"wpforms-649-field_5_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_5_3\">Phone<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_16-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Do you identify as Aboriginal and Torres Strait Islander?<\/legend><ul id=\"wpforms-649-field_16\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_16_1\" name=\"wpforms[fields][16]\" value=\"Yes\" aria-errormessage=\"wpforms-649-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_16_2\" name=\"wpforms[fields][16]\" value=\"No\" aria-errormessage=\"wpforms-649-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_16_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_16_3\" name=\"wpforms[fields][16]\" value=\"Unknown\" aria-errormessage=\"wpforms-649-field_16_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_16_3\">Unknown<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_17\">Residential Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-649-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-649-field_17-error\" required><\/div><div id=\"wpforms-649-field_18-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Is there a Guardianship and\/or Administration order in place?<\/legend><ul id=\"wpforms-649-field_18\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_18_1\" name=\"wpforms[fields][18]\" value=\"Yes\" aria-errormessage=\"wpforms-649-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_18_2\" name=\"wpforms[fields][18]\" value=\"No\" aria-errormessage=\"wpforms-649-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_18_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_6-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_6\">Disability \/ Medical Conditions<\/label><textarea id=\"wpforms-649-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-649-field_6-error\" aria-describedby=\"wpforms-649-field_6-description\" ><\/textarea><div id=\"wpforms-649-field_6-description\" class=\"wpforms-field-description\">Disability \/ Medical Conditions including any diagnosis if relevant.<\/div><\/div><div id=\"wpforms-649-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_19\">Doctors Name<\/label><input type=\"text\" id=\"wpforms-649-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-649-field_19-error\" ><\/div><div id=\"wpforms-649-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_20\">Phone Number<\/label><input type=\"text\" id=\"wpforms-649-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-649-field_20-error\" ><\/div><div id=\"wpforms-649-field_21-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\">Funding Source <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-649-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_21_1\" name=\"wpforms[fields][21]\" value=\"NDIA Managed\" aria-errormessage=\"wpforms-649-field_21_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_21_1\">NDIA Managed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_21_2\" name=\"wpforms[fields][21]\" value=\"Self Managed\" aria-errormessage=\"wpforms-649-field_21_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_21_2\">Self Managed<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_21_4\" name=\"wpforms[fields][21]\" value=\"Plan Managed\" aria-errormessage=\"wpforms-649-field_21_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_21_4\">Plan Managed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-649-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_22\">Goals and Aspirations<\/label><textarea id=\"wpforms-649-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-649-field_22-error\" aria-describedby=\"wpforms-649-field_22-description\" ><\/textarea><div id=\"wpforms-649-field_22-description\" class=\"wpforms-field-description\">What do you want to achieve for yourself \u2013 life skills, physically, socially etc?<\/div><\/div><div id=\"wpforms-649-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-649-field_23\">I understand that: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-649-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-649-field_23-error\" aria-describedby=\"wpforms-649-field_23-description\" required><div id=\"wpforms-649-field_23-description\" class=\"wpforms-field-description\">This form was completed by: (Provide name)<\/div><\/div><div id=\"wpforms-649-field_24-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">How did you hear about us? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-649-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-649-field_24_1\" name=\"wpforms[fields][24]\" value=\"Support 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duties\" aria-errormessage=\"wpforms-649-field_26_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_26_1\">Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_26_4\" name=\"wpforms[fields][26][]\" value=\"Records are archived for a set period according to policy and procedure\" aria-errormessage=\"wpforms-649-field_26_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-649-field_26_4\">Records are archived for a set period according to policy and procedure<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-649-field_26_5\" name=\"wpforms[fields][26][]\" value=\"I understand that all information obtained will be kept confidential.\" aria-errormessage=\"wpforms-649-field_26_5-error\" required 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