{"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_8217e783ba989fd33c06758696e19a2c\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_8217e783ba989fd33c06758696e19a2c\" 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'><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\"  ><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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reference is being provided for<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' 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\" \/>\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' 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How long have you known this individual?<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'   \/>\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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is\/was the nature of your relationship with this individual?<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'   \/>\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\"  ><label class='gfield_label gform-field-label' for='input_59_30'>*Other (please specify below)<\/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\"  ><label class='gfield_label gform-field-label' for='input_59_12'>Please provide a few comments about this individual<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\"  ><label class='gfield_label gform-field-label' for='input_59_33'>How would you describe this individulal as a caregiver?<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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<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' 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\" \/>\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' 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--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_59_10'>Your Phone<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'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/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\"  ><label class='gfield_label gform-field-label' for='input_59_2'>Your Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_59_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_59_14\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label 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