{"id":1397179,"date":"2025-12-19T14:33:48","date_gmt":"2025-12-19T19:33:48","guid":{"rendered":"https:\/\/fcsn.org\/?p=1397179"},"modified":"2025-12-19T14:34:53","modified_gmt":"2025-12-19T19:34:53","slug":"c2c-match-request-reference-form","status":"publish","type":"post","link":"https:\/\/fcsn.org\/vi\/c2c-match-request-reference-form\/","title":{"rendered":"Caregiver to Caregiver Respite Network (C2C) Reference Form"},"content":{"rendered":"<script>\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 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>This is the form to get details from the references that were provided in the C2C Match Form.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_59'  action='\/vi\/wp-json\/wp\/v2\/posts\/1397179' data-formid='59' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdJN-osAAAAAGaA3QLEIzmlcFHE8ixEcZ6Q6M7Y' data-tabindex='0'><input id=\"input_0730d6ae7ac4dc9b91e897fc22403599\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_0730d6ae7ac4dc9b91e897fc22403599\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_59' class='gform_fields top_label form_sublabel_above description_above validation_below' data-column-layout='fill'><div id=\"field_59_8\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"0fd84b02\" data-field-span=\"12\"><h3 class=\"gsection_title\">C2C Match Request: Reference Form<\/h3><\/div><fieldset id=\"field_59_23\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"37b55bf1\" data-field-span=\"12\"><legend id='gfield_label_59_23' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Reference is being provided for<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_59_23'>\n                            \n                            <span id='input_59_23_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_59_23_3' id='input_59_23_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_23.3' id='input_59_23_3' value=''   aria-required='true'    autocomplete=\"given-name\" aria-labelledby=\"input_59_23_3_label gfield_label_59_23\"\/>\n                                                <\/span>\n                            \n                            <span id='input_59_23_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_59_23_6' id='input_59_23_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_23.6' id='input_59_23_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_59_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"5b9a6468\" data-field-span=\"12\"><legend id='gfield_label_59_26' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>How long have you known this individual?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_59_26'><div class='gchoice gchoice_59_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='&lt;1 years'  id='choice_59_26_1'    aria-labelledby=\"label_59_26_1 gfield_label_59_26\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_59_26_1' id='label_59_26_1' class='gform-field-label gform-field-label--type-inline'>&lt;1 years<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='1-4 years'  id='choice_59_26_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_26_2' id='label_59_26_2' class='gform-field-label gform-field-label--type-inline'>1-4 years<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='5-9 years'  id='choice_59_26_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_26_3' id='label_59_26_3' class='gform-field-label gform-field-label--type-inline'>5-9 years<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='10+ years'  id='choice_59_26_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_26_4' id='label_59_26_4' class='gform-field-label gform-field-label--type-inline'>10+ years<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_59_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-seven-twelfths gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"fdf2dc27\" data-field-span=\"7\"><legend id='gfield_label_59_28' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is\/was the nature of your relationship with this individual?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_59_28'><div class='gchoice gchoice_59_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Family Member'  id='choice_59_28_1'    aria-labelledby=\"label_59_28_1 gfield_label_59_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_59_28_1' id='label_59_28_1' class='gform-field-label gform-field-label--type-inline'>Family Member<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Friend'  id='choice_59_28_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_28_2' id='label_59_28_2' class='gform-field-label gform-field-label--type-inline'>Friend<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Co-worker'  id='choice_59_28_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_28_3' id='label_59_28_3' class='gform-field-label gform-field-label--type-inline'>Co-worker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Relative'  id='choice_59_28_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_28_4' id='label_59_28_4' class='gform-field-label gform-field-label--type-inline'>Relative<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Community Member'  id='choice_59_28_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_28_5' id='label_59_28_5' class='gform-field-label gform-field-label--type-inline'>Community Member<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_59_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='*Other'  id='choice_59_28_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_59_28_6' id='label_59_28_6' class='gform-field-label gform-field-label--type-inline'>*Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_59_30\" class=\"gfield gfield--type-text gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"fdf2dc27\" data-field-span=\"5\"><label id='gfield_label_59_30' class='gfield_label gform-field-label' for='input_59_30'><span class='gform-field-label__text'>*Other (please specify below)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_59_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_59_12\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"a9d1642a\" data-field-span=\"12\"><label id='gfield_label_59_12' class='gfield_label gform-field-label' for='input_59_12'><span class='gform-field-label__text'>Please provide a few comments about this individual<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_59_12' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_59_33\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"582cce96\" data-field-span=\"12\"><label id='gfield_label_59_33' class='gfield_label gform-field-label' for='input_59_33'><span class='gform-field-label__text'>How would you describe this individulal as a caregiver?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_59_33' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_59_1\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"73bbb26d\" data-field-span=\"12\"><legend id='gfield_label_59_1' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_59_1'>\n                            \n                            <span id='input_59_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_59_1_3' id='input_59_1_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_59_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" aria-labelledby=\"input_59_1_3_label gfield_label_59_1\"\/>\n                                                <\/span>\n                            \n                            <span id='input_59_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_59_1_6' id='input_59_1_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_59_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_59_10\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"392e8457\" data-field-span=\"6\"><label id='gfield_label_59_10' class='gfield_label gform-field-label' for='input_59_10'><span class='gform-field-label__text'>Your Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_59_10' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_59_2\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"392e8457\" data-field-span=\"6\"><label id='gfield_label_59_2' class='gfield_label gform-field-label' for='input_59_2'><span class='gform-field-label__text'>Your Email Address<\/span><span class=\"gfield_required\"><span 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