{"id":4295,"date":"2022-02-18T19:16:58","date_gmt":"2022-02-18T19:16:58","guid":{"rendered":"https:\/\/www.comfortkeepers.ca\/newmarket\/?page_id=4295"},"modified":"2022-06-30T19:31:49","modified_gmt":"2022-06-30T19:31:49","slug":"take-our-care-survey","status":"publish","type":"page","link":"https:\/\/www.comfortkeepers.ca\/newmarket\/comfort-keepers\/take-our-care-survey\/","title":{"rendered":"Take Our Care Survey"},"content":{"rendered":"<div class=\"vc_row wpb_row vc_row-fluid\">\n<div class=\"wpb_column vc_column_container vc_col-sm-12\">\n<div class=\"vc_column-inner \">\n<div class=\"wpb_wrapper\">\n<div class=\"wpb_text_column wpb_content_element \">\n<div class=\"wpb_wrapper\">\n<div id=\"pagecontent\">\n<h1>Survey: Do You Need Homecare Services?<\/h1>\n<h2>Find out today if your loved one could benefit from homecare services in Newmarket, ON<\/h2>\n<p>It may be time for you to consider homecare services for your loved one! Start by taking our short Care Survey to help you better understand whether the time may have come to pursue homecare services options for your loved one.<br>Just answer \u201cYes\u201d or \u201cNo\u201d for each of the questions below.<\/p>\n<p><strong>Check \u201cYes\u201d or \u201cNo\u201d for the questions below: *<\/strong><\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\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='\/newmarket\/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'>URL<\/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 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