{"id":4295,"date":"2022-02-18T19:16:58","date_gmt":"2022-02-18T19:16:58","guid":{"rendered":"https:\/\/www.comfortkeepers.ca\/guelph\/?page_id=4295"},"modified":"2025-04-14T19:55:35","modified_gmt":"2025-04-14T19:55:35","slug":"take-our-care-survey","status":"publish","type":"page","link":"https:\/\/www.comfortkeepers.ca\/guelph\/contact\/take-our-care-survey\/","title":{"rendered":"Take Our Care Survey"},"content":{"rendered":"<h2 id=\"landerimage\">Quiz: Do You or Your Loved One Need Care?<\/h2>\n<p>The answer to whether or not care is needed isn\u2019t always easy. \u00a0If you have been considering care for either yourself or a loved one, start by taking our short quiz to help you better understand whether the time may have come to pursue care.<\/p>\n<\/p>\n\n<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 InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework survey_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' ><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Care Survey<\/h2>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4' class='survey' action='\/guelph\/wp-json\/wp\/v2\/pages\/4295#gf_4' data-formid='4' novalidate>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_0' style='width:0%; color:#fff; background-color:#29A8DE;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_17\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Facebook<\/label><div class='ginput_container'><input name='input_17' id='input_4_17' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_17'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above 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' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First Name *<\/label>\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last Name *<\/label>\n                                                            <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_2' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page #gform_wrapper_4' data-js='page-field-id-2' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_4_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Who needs care?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_3'>\n\t\t\t<div class='gchoice gchoice_4_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Myself'  id='choice_4_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_3_0' id='label_4_3_0' class='gform-field-label gform-field-label--type-inline'>Myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='My Loved One'  id='choice_4_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_3_1' id='label_4_3_1' class='gform-field-label gform-field-label--type-inline'>My Loved One<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_5' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_5' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_3' class='gform_page' data-js='page-field-id-5' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_4_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required 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' >Choose the following statements that apply to you\/your loved one:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_4'><div class='gchoice gchoice_4_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Do you wear clothing that is dirty or has food stains?'  id='choice_4_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_1' id='label_4_4_1' class='gform-field-label gform-field-label--type-inline'>Do you wear clothing that is dirty or has food stains?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='Do you wear your nightclothes during the day?'  id='choice_4_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_2' id='label_4_4_2' class='gform-field-label gform-field-label--type-inline'>Do you wear your nightclothes during the day?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='Do you wear the same outfit day after day?'  id='choice_4_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_3' id='label_4_4_3' class='gform-field-label gform-field-label--type-inline'>Do you wear the same outfit day after day?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='Are you not showering or bathing?'  id='choice_4_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_4' id='label_4_4_4' class='gform-field-label gform-field-label--type-inline'>Are you not showering or bathing?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.5' type='checkbox'  value='Do you fail to comb\/style your hair or brush your teeth?'  id='choice_4_4_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_5' id='label_4_4_5' class='gform-field-label gform-field-label--type-inline'>Do you fail to comb\/style your hair or brush your teeth?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.6' type='checkbox'  value='Are you losing weight?'  id='choice_4_4_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_6' id='label_4_4_6' class='gform-field-label gform-field-label--type-inline'>Are you losing weight?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.7' type='checkbox'  value='Have you fallen or is there unusual tearing or bruising of the skin that may indicate you&#039;ve fallen?'  id='choice_4_4_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_7' id='label_4_4_7' class='gform-field-label gform-field-label--type-inline'>Have you fallen or is there unusual tearing or bruising of the skin that may indicate you&#8217;ve fallen?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.8' type='checkbox'  value='Are you failing to recognize people or know their name?'  id='choice_4_4_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_8' id='label_4_4_8' class='gform-field-label gform-field-label--type-inline'>Are you failing to recognize people or know their name?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.9' type='checkbox'  value='Do you fail to speak normally or have trouble communicating?'  id='choice_4_4_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_9' id='label_4_4_9' class='gform-field-label gform-field-label--type-inline'>Do you fail to speak normally or have trouble communicating?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.11' type='checkbox'  value='Are you having confusion such as not knowing the date, where you are, or, the season of the year?'  id='choice_4_4_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_11' id='label_4_4_11' class='gform-field-label gform-field-label--type-inline'>Are you having confusion such as not knowing the date, where you are, or, the season of the year?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.12' type='checkbox'  value='Have you withdrawn socially or are you less communicative?'  id='choice_4_4_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_12' id='label_4_4_12' class='gform-field-label gform-field-label--type-inline'>Have you withdrawn socially or are you less communicative?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.13' type='checkbox'  value='Are there foul smells coming from your refrigerator or cupboards?'  id='choice_4_4_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_13' id='label_4_4_13' class='gform-field-label gform-field-label--type-inline'>Are there foul smells coming from your refrigerator or cupboards?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.14' type='checkbox'  value='Are your cupboards void of nutritious foods?'  id='choice_4_4_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_14' id='label_4_4_14' class='gform-field-label gform-field-label--type-inline'>Are your cupboards void of nutritious foods?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.15' type='checkbox'  value='Is you home cluttered and does it have newspapers and mail accumulating?'  id='choice_4_4_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_15' id='label_4_4_15' class='gform-field-label gform-field-label--type-inline'>Is you home cluttered and does it have newspapers and mail accumulating?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.16' type='checkbox'  value='Do you have expired medications or medications that are not being taken?'  id='choice_4_4_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_16' id='label_4_4_16' class='gform-field-label gform-field-label--type-inline'>Do you have expired medications or medications that are not being taken?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_4_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.17' type='checkbox'  value='None of the above apply'  id='choice_4_4_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_4_17' id='label_4_4_17' class='gform-field-label gform-field-label--type-inline'>None of the above apply<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_7' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_4' class='gform_page' data-js='page-field-id-7' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_10\" class=\"gfield gfield--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\"  ><h2>You have come to the right place.<\/h2>\n<p>You could benefit from in-home care.<br>\nWe are here for you and would like to contact you and assist you in your in-home care needs.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_9' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_5' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_11\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_11'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_4_11' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_8' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_8' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_6' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_12\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description 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