{"id":27459,"date":"2023-03-09T14:56:23","date_gmt":"2023-03-09T19:56:23","guid":{"rendered":"https:\/\/gthhv2.goldentouch.nyc\/enroll-form\/"},"modified":"2023-09-28T15:28:31","modified_gmt":"2023-09-28T19:28:31","slug":"enroll","status":"publish","type":"page","link":"https:\/\/goldentouchhomehealth.com\/en\/enroll\/","title":{"rendered":"Apply for Home Care Services"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row bg_type=&#8221;bg_color&#8221; bg_override=&#8221;full&#8221; paroller_image=&#8221;&#8221; bg_color_value=&#8221;#25408f&#8221;][vc_column]<div id=\"ultimate-heading-435469dfc607d599f\" class=\"uvc-heading ult-adjust-bottom-margin ultimate-heading-435469dfc607d599f uvc-6082 \" data-hspacer=\"line_only\"  data-halign=\"left\" style=\"text-align:left\"><div class=\"uvc-main-heading ult-responsive\"  data-ultimate-target='.uvc-heading.ultimate-heading-435469dfc607d599f p'  data-responsive-json-new='{\"font-size\":\"desktop:48px;\",\"line-height\":\"\"}' ><p style=\"font-weight:normal;color:#ffffff;\">Apply for Home Care Services<\/p><\/div><div class=\"uvc-heading-spacer line_only\" style=\"topheight:1px;\"><span class=\"uvc-headings-line\" style=\"border-style:solid;border-bottom-width:1px;border-color:#e5a92e;width:autopx;\"><\/span><\/div><\/div>[vc_single_image image=&#8221;27452&#8243; img_size=&#8221;full&#8221; alignment=&#8221;center&#8221; style=&#8221;vc_box_rounded&#8221; css=&#8221;.vc_custom_1678375460481{padding-top: 20px !important;}&#8221;][\/vc_column][\/vc_row][vc_row bg_type=&#8221;bg_color&#8221; bg_override=&#8221;full&#8221; seperator_enable=&#8221;seperator_enable_value&#8221; seperator_type=&#8221;tilt_left_seperator&#8221; seperator_svg_height=&#8221;70&#8243; seperator_shape_background=&#8221;#25408f&#8221; paroller_image=&#8221;&#8221; bg_color_value=&#8221;#ffffff&#8221;][vc_column][vc_empty_space height=&#8221;70px&#8221;][vc_column_text]<span style=\"color: #000000; font-size: 28px;\">Please select your service, then fill out the form, Golden Touch will contact you within 48 hours!<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column css=&#8221;.vc_custom_1678376478145{margin-top: -30px !important;}&#8221;][vc_column_text]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Enrollment<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/en\/wp-json\/wp\/v2\/pages\/27459' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_1\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\" ><label class='gfield_label gform-field-label' for='input_4_1'>Select your service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_4_1' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select the service you want to apply for<\/option><option value='CDPAP' >CDPAP<\/option><option value='PCA &amp; HHA' >PCA &amp; HHA<\/option><\/select><\/div><\/div><fieldset id=\"field_4_3\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >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_4_3'>\n                            \n                            <span id='input_4_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_4_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_3_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_4_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_3_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_5\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_5\" ><label class='gfield_label gform-field-label' for='input_4_5'>Phone Number:<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_5' id='input_4_5' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_12\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_12\" ><label class='gfield_label gform-field-label' for='input_4_12'>E-mail:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_4_12' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_4_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_6\" ><legend class='gfield_label gform-field-label' >Is it the applicant himself\/herself?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_6'>\n\t\t\t<div class='gchoice gchoice_4_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Yes'  id='choice_4_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_0' id='label_4_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_4_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_1' id='label_4_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div data-fieldId=\"6\" class=\"spacer gfield\" style=\"grid-column: span 9;\" data-groupId=\"d19b4a44\"><\/div><fieldset id=\"field_4_7\" 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\"  data-js-reload=\"field_4_7\" ><legend class='gfield_label gform-field-label' >Do you have Medicaid?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_7'>\n\t\t\t<div class='gchoice gchoice_4_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_4_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_7_0' id='label_4_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_4_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_7_1' id='label_4_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_8\" 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\"  data-js-reload=\"field_4_8\" ><legend class='gfield_label gform-field-label' >Are you applying for long-term care for the first time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_8'>\n\t\t\t<div class='gchoice gchoice_4_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_4_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_8_0' id='label_4_8_0' class='gform-field-label 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