1 2<!DOCTYPE html> 3<html lang="en"> 4<head> 5<meta charset="utf-8"> 6<meta http-equiv="X-UA-Compatible" content="IE=edge"> 7<meta name="viewport" content="width=device-width, initial-scale=1.0"> 8<link rel="preconnect" href="https://code.jquery.com" crossorigin> 9<link rel="preconnect" href="https://ajax.googleapis.com" crossorigin> 10<link rel="preconnect" href="https://stackpath.bootstrapcdn.com" crossorigin> 11<link rel="preconnect" href="https://cdnjs.cloudflare.com" crossorigin> 12<link rel="preconnect" href="https://fonts.gstatic.com" crossorigin> 13<title>Community Partnerships, Companies & Foundations</title> 14<link rel="canonical" href="https://vnacolorado.org/Community-Partnerships-Companies-Foundations"> 15<meta name="description" content="Partner with Colorado VNA to improve senior healthcare in Denver. Support our mission through community partnerships, grants, and charitable giving."> 16<meta property="og:title" content="Community Partnerships, Companies & Foundations"> 17<meta property="og:description" content="Partner with Colorado VNA to improve senior healthcare in Denver. Support our mission through community partnerships, grants, and charitable giving."> 18<meta property="og:url" content="https://vnacolorado.org/Community-Partnerships-Companies-Foundations"> 19<meta property="og:type" content="website"> 20<meta property="og:site_name" content="vnacolorado.org"> 21<meta property="og:image" content="https://vnacolorado.org/userfiles/2706/images/subhero.jpg"> 22<meta name="twitter:card" content="summary_large_image"> 23<meta name="twitter:title" content="Community Partnerships, Companies & Foundations"> 24<meta name="twitter:description" content="Partner with Colorado VNA to improve senior healthcare in Denver. Support our mission through community partnerships, grants, and charitable giving."> 25<meta name="twitter:image" content="https://vnacolorado.org/userfiles/2706/images/subhero.jpg"> 26<meta name="author" content="Omnia Business Systems"> 27<link rel="shortcut icon" href="/userfiles/2706/fav.png"> 28<!-- omsPerf lite=1 eagerMaps=0 deferBs=0 hover=0 hamb=0 par=0 mas=0 | edit=0 page=1 tpl=_blank.cfm plain=1 incl=0 detail=0 jqui=0 fpjs=0 maps=0 forced=0 --> 29<!-- Modified Bootstrap CSS --> 30<link href="/sass/src/css/2706.css?t=1770835791" rel="stylesheet"> 31<!-- Google Fonts CSS --> 32<link href="//fonts.googleapis.com/css?family=Open+Sans:400,700&display=swap" rel="stylesheet" type="text/css"> 33<link href="//fonts.googleapis.com/css?family=Montserrat:400,700&display=swap" rel="stylesheet" type="text/css"> 34<link href="/css/omnia.css?v=1727825914" rel="stylesheet">
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42 43<style> 44.signedIn{display:none!important} 45.signedOut{display:block!important} 46</style> 47<style id="additionalStylesInline"> 48/* GLOBAL */ 49/* ==== */ 50html { 51scroll-behavior: smooth; 52} 53#savecontent { 54margin-top: -2px; 55} 56.codey { 57font-family: courier, monospace; 58} 59.anchor { 60scroll-margin-top: 200px; 61} 62@media(min-width: 576px) { 63h1, .h1 { 64font-size: 2.7rem; 65} 66h2, 67.h2 { 68font-size: 2.4rem; 69} 70h3, 71.h3 { 72font-size: 2.1rem; 73} 74h4, 75.h4 { 76font-size: 1.9rem; 77} 78h5, 79.h5 { 80font-size: 1.6rem; 81} 82h6, 83.h6 { 84font-size: 1.3rem; 85} 86} 87@media(min-width: 768px) { 88h1, .h1 { 89font-size: 3.1rem; 90} 91h2, 92.h2 { 93font-size: 2.75rem; 94} 95h3, 96.h3 { 97font-size: 2.4rem; 98} 99h4, 100.h4 { 101font-size: 2.05rem; 102} 103h5, 104.h5 { 105font-size: 1.7rem; 106} 107h6, 108.h6 { 109font-size: 1.35rem; 110} 111} 112@media(min-width: 1200px) { 113h1.mega, .h1.mega { 114font-size: 4.5rem !important; 115} 116body { 117font-size: 1.1rem; 118} 119h1, 120.h1 { 121font-size: 3.4rem; 122} 123h2, 124.h2 { 125font-size: 3rem; 126} 127h3, 128.h3 { 129font-size: 2.6rem; 130} 131h4, 132.h4 { 133font-size: 2.2rem; 134} 135h5, 136.h5 { 137font-size: 1.8rem; 138} 139h6, 140.h6 { 141font-size: 1.4rem; 142} 143} 144@media(min-width: 1600px) { 145h1, .h1 { 146font-size: 3.8rem; 147} 148h2, 149.h2 { 150font-size: 3.25rem; 151} 152h3, 153.h3 { 154font-size: 2.8rem; 155} 156h4, 157.h4 { 158font-size: 2.35rem; 159} 160h5, 161.h5 { 162font-size: 1.9rem; 163} 164h6, 165.h6 { 166font-size: 1.45rem; 167} 168} 169.btn { 170white-space: normal; 171} 172a:hover img, 173a.bg-img:hover a.bg-image:hover { 174opacity: .85; 175} 176a:not(.btn):hover { 177color: var(--success) !important; 178} 179#savecontent img { 180max-width: 100% !important; 181height: auto !important; 182} 183.rightfloat { 184float: right; 185margin: 0 0 .5rem 1rem; 186width: 40%; 187} 188@media (max-width: 767px) { 189.rightfloat { 190float: none; 191margin: 0 0 1rem 0; 192width: 100%; 193} 194} 195.btn-primary { 196color: white !important; 197} 198.round { 199border-radius: 12px; 200} 201.carousel-control-next-icon, 202.carousel-control-prev-icon { 203background-color: rgba(0, 0, 0, 0.9); 204padding: 1rem; 205background-size: 20px; 206} 207@media(min-width: 1600px) { 208.container { 209max-width: 1300px; 210} 211} 212@media(min-width: 1600px) { 213.container.container-wide { 214width: 1500px !important; 215max-width: 1500px !important; 216} 217} 218.product-image { 219background-size: cover !important; 220min-height: auto !important; 221padding-bottom: 75%; 222} 223#savecontent form label { 224font-weight: bold; 225} 226#savecontent form .checkbox-group label, 227#savecontent form .radio-group label { 228font-weight: normal; 229} 230.formbuilder-required { 231color: red; 232} 233.text-right.addToCart { 234text-align: left !important; 235} 236.blog-detail-page { 237background: var(--light); 238} 239.blog-detail-page .blog { 240border-radius: 12px; 241padding: 1.5rem; 242background: white; 243box-shadow: 4px 4px 8px rgba(0, 0, 0, 0.2); 244} 245.blog-detail-page .blog h4 { 246margin-top: 1rem; 247} 248form li p { 249margin-bottom: 0; 250} 251form label { 252font-weight: bold; 253} 254form .checkbox-group label, 255form .radio-group label { 256font-weight: normal; 257} 258.formbuilder-checkbox, 259.formbuilder-radio { 260margin-bottom: 4px; 261} 262#savecontent ul:not(.pagination) { 263list-style: none; 264padding: 0 15px; 265} 266#savecontent ul:not(.pagination) li { 267position: relative; 268padding-left: 30px; 269} 270#savecontent ul:not(.pagination):not(.nav-pills) li:before { 271content: ""; 272position: absolute; 273left: 0; 274top: 6px; 275/* top: 50%; 276transform: translateY(-50%);*/ 277width: 16px; 278height: 16px; 279background-image: url('/userfiles/2706/images/check.png'); 280/* Example image */ 281background-size: cover; 282background-repeat: no-repeat; 283} 284/* PAGE SPECIFIC */ 285/* FOOTER */ 286</style>
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298 299 <link href="https://fonts.googleapis.com/css2?family=DM+Sans:wght@300;400;500;600&family=DM+Mono:wght@400;500&display=swap" rel="stylesheet"> 300 <style> 301 #omniaMgmtLoginModal { 302 font-family: 'DM Sans', sans-serif; 303 } 304 #omniaMgmtLoginModal .modal-dialog { 305 max-width: 420px; 306 } 307 #omniaMgmtLoginModal .modal-content { 308 background: #16161e; 309 border: 1px solid rgba(255,255,255,0.07); 310 border-radius: 20px; 311 box-shadow: 0 32px 80px rgba(0,0,0,0.6), 0 0 0 1px rgba(91,94,244,0.1); 312 overflow: hidden; 313 position: relative; 314 } 315 #omniaMgmtLoginModal .modal-header { 316 border: none; 317 padding: 32px 32px 0 32px; 318 display: flex; 319 align-items: center; 320 justify-content: center; 321 } 322 #omniaMgmtLoginModal .modal-header .header-inner { 323 display: flex; 324 flex-direction: column; 325 align-items: center; 326 text-align: center; 327 width: 100%; 328 } 329 #omniaMgmtLoginModal .modal-icon { 330 width: 48px; 331 height: 48px; 332 background: linear-gradient(135deg, #5b5ef4, #8b5cf6); 333 border-radius: 14px; 334 display: flex; 335 align-items: center; 336 justify-content: center; 337 margin-bottom: 16px; 338 } 339 #omniaMgmtLoginModal .modal-icon svg { 340 width: 22px; height: 22px; 341 stroke: #fff; fill: none; 342 stroke-width: 2; stroke-linecap: round; stroke-linejoin: round; 343 } 344 #omniaMgmtLoginModal .modal-title { 345 font-size: 20px; 346 font-weight: 600; 347 color: #f0f0f8; 348 letter-spacing: -0.02em; 349 margin-bottom: 4px; 350 } 351 #omniaMgmtLoginModal .modal-subtitle { 352 font-size: 14px; 353 color: #666; 354 line-height: 1.5; 355 } 356 357 /* Close button */ 358 #omniaMgmtLoginModal .btn-close-modal { 359 position: absolute; 360 top: 16px; 361 right: 16px; 362 background: rgba(255,255,255,0.06); 363 border: none; 364 color: #888; 365 width: 30px; 366 height: 30px; 367 border-radius: 8px; 368 cursor: pointer; 369 display: flex; 370 align-items: center; 371 justify-content: center; 372 font-size: 16px; 373 line-height: 1; 374 transition: background 0.15s, color 0.15s; 375 z-index: 10; 376 } 377 #omniaMgmtLoginModal .btn-close-modal:hover { background: rgba(255,255,255,0.12); color: #e8e8f0; } 378 #omniaMgmtLoginModal .btn-close-modal:focus { outline: none; box-shadow: none; } 379 380 /* Fields */ 381 #omniaMgmtLoginModal .login-field { 382 margin-bottom: 16px; 383 } 384 #omniaMgmtLoginModal .login-field label { 385 display: block; 386 font-size: 11px; 387 font-weight: 500; 388 color: #888; 389 letter-spacing: 0.07em; 390 text-transform: uppercase; 391 margin-bottom: 8px; 392 } 393 #omniaMgmtLoginModal .login-input-wrap { 394 position: relative; 395 display: flex; 396 align-items: center; 397 } 398 #omniaMgmtLoginModal .login-input-wrap input { 399 width: 100%; 400 background: #0f0f13; 401 border: 1.5px solid #2a2a35; 402 border-radius: 10px; 403 padding: 12px 44px 12px 14px; 404 color: #e8e8f0; 405 font-family: 'DM Sans', sans-serif; 406 font-size: 14px; 407 outline: none; 408 transition: border-color 0.2s, box-shadow 0.2s; 409 } 410 #omniaMgmtLoginModal .login-input-wrap input::placeholder { 411 color: #3a3a4a; 412 font-size: 14px; 413 } 414 #omniaMgmtLoginModal .login-input-wrap input:focus { 415 border-color: #5b5ef4; 416 box-shadow: 0 0 0 3px rgba(91,94,244,0.15); 417 } 418 #omniaMgmtLoginModal .login-toggle-pw { 419 position: absolute; 420 right: 12px; 421 background: none; 422 border: none; 423 color: #444; 424 cursor: pointer; 425 padding: 4px; 426 display: flex; 427 align-items: center; 428 transition: color 0.15s; 429 } 430 #omniaMgmtLoginModal .login-toggle-pw:hover { color: #888; } 431 #omniaMgmtLoginModal .login-toggle-pw svg { 432 width: 16px; height: 16px; 433 stroke: currentColor; fill: none; 434 stroke-width: 2; stroke-linecap: round; stroke-linejoin: round; 435 } 436 437 /* Auth code field (shown dynamically) */ 438 #omniaMgmtLoginModal .auth-field { margin-bottom: 16px; } 439 #omniaMgmtLoginModal #verification { 440 width: 100%; 441 background: #0f0f13; 442 border: 1.5px solid #fbbf24; 443 border-radius: 10px; 444 padding: 12px 14px; 445 color: #e8e8f0; 446 font-family: 'DM Mono', monospace; 447 font-size: 18px; 448 letter-spacing: 0.25em; 449 text-align: center; 450 outline: none; 451 transition: border-color 0.2s, box-shadow 0.2s; 452 } 453 #omniaMgmtLoginModal #verification:focus { 454 border-color: #fbbf24; 455 box-shadow: 0 0 0 3px rgba(251,191,36,0.15); 456 } 457 #omniaMgmtLoginModal #verification::placeholder { 458 letter-spacing: 0.05em; 459 font-size: 14px; 460 color: #3a3a4a; 461 font-family: 'DM Sans', sans-serif; 462 } 463 464 /* Case sensitive note */ 465 #omniaMgmtLoginModal .login-note { 466 font-size: 12px; 467 color: #fff; 468 text-align: center; 469 margin-bottom: 4px;
470 } 471 472 /* Error / response area */ 473 #omniaMgmtLoginModal .alert { 474 font-size: 13px; 475 min-height: 18px; 476 margin-bottom: 8px; 477 color: #f87171; 478 transition: opacity 0.2s; 479 line-height: 1.5; 480 } 481 #omniaMgmtLoginModal .login-alert:empty { margin-bottom: 0; } 482 #omniaMgmtLoginModal .alert { 483 background: rgba(255,255,255,0.04); 484 border: 1px solid rgba(255,255,255,0.08); 485 border-radius: 8px; 486 color: #a0a0b8; 487 font-size: 13px; 488 padding: 10px 12px; 489 margin-top: 6px; 490 } 491 /*#omniaMgmtLoginModal .alert a { color: #8b5cf6; }*/ 492 493 /* SMS button */ 494 #omniaMgmtLoginModal .btn-sms { 495 width: 100%; 496 background: rgba(251,191,36,0.12); 497 border: 1px solid rgba(251,191,36,0.3); 498 color: #fbbf24; 499 border-radius: 10px; 500 padding: 11px; 501 font-family: 'DM Sans', sans-serif; 502 font-size: 14px; 503 font-weight: 500; 504 cursor: pointer; 505 transition: background 0.2s; 506 margin-bottom: 12px; 507 } 508 #omniaMgmtLoginModal .btn-sms:hover { background: rgba(251,191,36,0.2); } 509 510 /* Modal body / footer */ 511 #omniaMgmtLoginModal .modal-body { 512 padding: 24px 32px 16px 32px; 513 } 514 #omniaMgmtLoginModal .modal-footer { 515 border: none; 516 padding: 8px 32px 32px 32px; 517 display: flex; 518 flex-direction: column; 519 gap: 10px; 520 } 521 522 /* Primary login button */ 523 #omniaMgmtLoginModal .btn-login { 524 width: 100%; 525 background: linear-gradient(135deg, #5b5ef4, #8b5cf6); 526 color: #fff; 527 border: none; 528 padding: 13px; 529 border-radius: 10px; 530 font-family: 'DM Sans', sans-serif; 531 font-size: 15px; 532 font-weight: 600; 533 cursor: pointer; 534 letter-spacing: 0.01em; 535 transition: opacity 0.2s, transform 0.15s, box-shadow 0.2s; 536 position: relative; 537 overflow: hidden; 538 } 539 #omniaMgmtLoginModal .btn-login:hover { 540 transform: translateY(-1px); 541 box-shadow: 0 8px 24px rgba(91,94,244,0.4); 542 } 543 #omniaMgmtLoginModal .btn-login:active { transform: translateY(0); } 544 545 /* Forgot password link-style button */ 546 #omniaMgmtLoginModal .btn-forgot { 547 width: 100%; 548 background: rgba(255,255,255,0.04); 549 border: 1px solid rgba(255,255,255,0.07); 550 color: #666; 551 border-radius: 10px; 552 padding: 11px; 553 font-family: 'DM Sans', sans-serif; 554 font-size: 14px; 555 font-weight: 500; 556 cursor: pointer; 557 transition: background 0.2s, color 0.2s; 558 } 559 #omniaMgmtLoginModal .btn-forgot:hover { background: rgba(255,255,255,0.08); color: #a0a0b8; } 560 561 /* Back button on forgot screen */ 562 #omniaMgmtLoginModal .btn-back-login { 563 background: none; 564 border: none; 565 color: #5b5ef4; 566 font-family: 'DM Sans', sans-serif; 567 font-size: 13px; 568 font-weight: 500; 569 cursor: pointer; 570 padding: 0; 571 display: inline-flex; 572 align-items: center; 573 gap: 5px; 574 margin-bottom: 16px; 575 transition: color 0.15s; 576 outline: none; 577 box-shadow: none; 578 } 579 #omniaMgmtLoginModal .btn-back-login:hover { color: #8b5cf6; } 580 #omniaMgmtLoginModal .btn-back-login:focus { outline: none; box-shadow: none; } 581 #omniaMgmtLoginModal .btn-back-login svg { 582 width: 14px; height: 14px; 583 stroke: currentColor; fill: none; 584 stroke-width: 2; stroke-linecap: round; stroke-linejoin: round; 585 } 586 587 /* Ripple */ 588 #omniaMgmtLoginModal .btn-login .ripple { 589 position: absolute; 590 border-radius: 50%; 591 background: rgba(255,255,255,0.25); 592 transform: scale(0); 593 animation: loginRipple 0.5s linear; 594 pointer-events: none; 595 } 596 @keyframes loginRipple { to { transform: scale(4); opacity: 0; } } 597 598 .modal-backdrop { background: rgba(5,5,10,0.75); } 599 .modal-backdrop.show { opacity: 1; } 600 </style> 601 602
602<script> 603 $(function(){ 604 605 /* auth spinner: PBKDF2 verify adds ~1-2s to each login step (incident 2026-09-10) */ 606 $('head').append('<style>.omnia-spin{display:inline-block;width:1rem;height:1rem;margin-right:.5rem;vertical-align:-2px;border:2px solid currentColor;border-right-color:transparent;border-radius:50%;animation:omniaSpin .6s linear infinite;}@keyframes omniaSpin{to{transform:rotate(360deg)}}</style>'); 607 function omniaLoginLoading(on){ 608 var $b = $('#loginSubmitted'); 609 if(!$b.length) return; 610 if(on){ if($b.data('omniaOrig')===undefined){ $b.data('omniaOrig', $b.html()); } $b.prop('disabled', true).css('cursor','wait').html('<span class="omnia-spin"></span>Signing in...'); } 611 else { if($b.data('omniaOrig')!==undefined){ $b.html($b.data('omniaOrig')); } $b.prop('disabled', false).css('cursor',''); } 612 } 613 $(document).ajaxSend(function(e, xhr, opts){ var d = opts.data || ''; if(/func=checkPWSecurity/.test(d) || /method=loginCheck_a/.test(opts.url||'')) omniaLoginLoading(true); }); 614 $(document).ajaxComplete(function(e, xhr, opts){ var d = opts.data || ''; var cp = /func=checkPWSecurity/.test(d); var lc = /method=loginCheck_a/.test(opts.url||''); if(cp && $.trim(xhr.responseText) === 'success') return; if(cp || lc) omniaLoginLoading(false); }); 615 // ââ Login submit (button + Enter key) ââââââââââââââââââââââââââââââ 616 var loginPending = false; 617 function doLogin(){ 618 if(loginPending) return; 619 loginPending = true; 620 var data = $('#loginForm').serialize() + "&func=checkPWSecurity"; 621 $.post("/ajax/generic_functions.cfm", data, function(response){ 622 loginPending = false; 623 if($.trim(response) == 'success'){ 624 var data = $("#loginForm").serialize(); 625 $.post("/com/security.cfc?method=loginCheck_a", data, function(response){ 626 if($.trim(response) == "success"){ 627 parent.window.location.href = "/secure/"; 628 } else if($.trim(response).substr(0,8) == "redirect"){ 629 parent.window.location.href = $.trim(response).substring(9, response.length); 630 } else { 631 if(~response.indexOf("credentials")){ $('#forceLogin').val('1'); } 632 $('#loginAlert').html('<p class="mb-2 text-white">' + response + '</p>'); 633 } 634 }, "html"); 635 } else if(~$.trim(response).indexOf("checkauth")){ 636 $('.auth-item').remove(); 637 $('#loginAlert').html('<p class="mb-2 text-white">A 6-digit code has been sent to your email.</p><div class="alert">Please add <strong style="color:#f87171;">[email protected]</strong> to your safe sender list if you are still not receiving the code.</div>'); 638 $('.login-username-field, .login-pw-field').hide(); 639 // Auth code input 640 $('#omniaMgmtLoginModal .modal-body').append('<div class="auth-field auth-item"><label style="display:block;font-size:11px;font-weight:500;color:#888;letter-spacing:0.07em;text-transform:uppercase;margin-bottom:8px;">Verification Code</label><input type="text" name="verification" id="verification" maxlength="6" placeholder="Enter 6-digit code" autocomplete="off" form="loginForm"></div>'); 641 if($.trim(response) == "checkauthwithphone"){ 642 $('#omniaMgmtLoginModal .modal-body').append('<div class="auth-item" style="margin-bottom:8px;font-size:12px;color:#666;text-align:center;">Not receiving the email?</div><button type="button" id="sendSMS" class="btn-sms auth-item">Send Code Via Text</button>'); 643 } else { 644 $('#omniaMgmtLoginModal .modal-body').append('<div class="auth-item" style="margin-bottom:4px;"><div class="alert text-center">Not receiving the email? Contact us at <strong style="color:#f87171;"><a href="mailto:[email protected]">[email protected]</a></strong> to add a phone number for text verification.</div></div>'); 645 } 646 } else if($.trim(response) == 'not verified'){ 647 $('#loginAlert').html('<p class="mb-2 text-white">The authorization code is incorrect. If you continue to have issues, refresh and try again.</p>'); 648 setTimeout(function(){ $('#omniaMgmtLoginModal').modal('hide'); }, 2000); 649 } else if($.trim(response) == 'no match'){ 650 $('#loginAlert').html('<p class="mb-2 text-white">No user matches these credentials.</p>'); 651 } else { 652 $.post("/ajax/generic_functions.cfm", { func: "getEmailForPasswordReset", username: $('#userName').val() }, function(response){ 653 $.post("/ajax/generic_functions.cfm", { func: "createResetPasswordEmail", username: $('#userName').val() }, function(){}, "html"); 654 $('#loginAlert').html('<p class="mb-2 text-white">Your password is not secure. You will receive an email at <strong>' + response + '</strong> momentarily to reset it.</p>'); 655 }, "html"); 656 } 657 }, "html"); 658 } 659 660 $('#loginSubmitted').on('click', function(e){
661 // Ripple effect 662 var btn = this, circle = document.createElement('span'); 663 var d = Math.max(btn.clientWidth, btn.clientHeight), r = d/2; 664 var rect = btn.getBoundingClientRect(); 665 circle.style.cssText = 'width:'+d+'px;height:'+d+'px;left:'+(e.clientX-rect.left-r)+'px;top:'+(e.clientY-rect.top-r)+'px'; 666 circle.className = 'ripple'; 667 $(btn).find('.ripple').remove(); 668 btn.appendChild(circle); 669 doLogin(); 670 }); 671 672 $(document).keydown(function(e){ 673 setTimezoneCookie(); 674 if(e.keyCode === 13 && $('#loginscreen').is(':visible')){ 675 // If the verification field exists and is visible, still call doLogin 676 // (it will serialize the verification value too since it has form="loginForm") 677 doLogin(); 678 } 679 if(e.keyCode === 13 && $('#forgotpassscreen').is(':visible')){ doForgot(); } 680 }); 681 682 // ââ SMS ââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââ 683 $(document).on('click', '#sendSMS', function(){ 684 var $btn = $(this); 685 $btn.prop('disabled', true); 686 $.post("/ajax/generic_functions.cfm", { func: "sendSMSAuth", username: $('#userName').val(), password: $('#password').val() }, function(){ 687 $btn.html('<i class="fas fa-check" style="margin-right:6px;"></i>Code Sent!'); 688 $btn.css({ 689 'background': 'rgba(34,197,94,0.15)', 690 'border-color': 'rgba(34,197,94,0.4)', 691 'color': '#22c55e' 692 }); 693 }, "html"); 694 }); 695 696 // ââ Forgot password ââââââââââââââââââââââââââââââââââââââââââââââââââ 697 $('.forgotUorP').on('click', function(){ 698 $('#loginscreen').hide(); 699 $('#forgotpassscreen').show(); 700 $('#loginAlert').html(''); 701 }); 702 703 $('.btn-back-login').on('click', function(){ 704 $('#forgotpassscreen').hide(); 705 $('#loginscreen').show(); 706 }); 707 708 $('#omniaMgmtLoginModal').on('hidden.bs.modal', function(){ 709 location.reload(); 710 }); 711 712 function doForgot(){ 713 var data = $("#forgotPassForm").serialize(); 714 $.post("/com/security.cfc?method=forgotPass", data, function(response){ 715 $('#loginAlert').html(response); 716 $('#forgotpassscreen').hide(); 717 $('#loginscreen').show(); 718 }, "html"); 719 } 720 721 $("#forgotPassForm").submit(function(e){ e.preventDefault(); doForgot(); }); 722 $('#submitRetrievePassword').on('click', doForgot); 723 }); 724 725 function setTimezoneCookie(){ 726 var timezone = jstz.determine(); 727 timezone = timezone.name(); 728 $.post("/ajax/generic_functions.cfm", { func: "setTimeZoneCookie", timezone: timezone }, function(){}, "html"); 729 } 730 731 function loginTogglePW(inputId, btn){ 732 var input = document.getElementById(inputId); 733 var isPassword = input.type === 'password'; 734 input.type = isPassword ? 'text' : 'password'; 735 var svg = btn.querySelector('svg'); 736 svg.innerHTML = isPassword 737 ? '<path d="M17.94 17.94A10.07 10.07 0 0 1 12 20c-7 0-11-8-11-8a18.45 18.45 0 0 1 5.06-5.94M9.9 4.24A9.12 9.12 0 0 1 12 4c7 0 11 8 11 8a18.5 18.5 0 0 1-2.16 3.19m-6.72-1.07a3 3 0 1 1-4.24-4.24"/><line x1="1" y1="1" x2="23" y2="23"/>' 738 : '<path d="M1 12s4-8 11-8 11 8 11 8-4 8-11 8-11-8-11-8z"/><circle cx="12" cy="12" r="3"/>'; 739 } 740 </script>
740<script type="application/ld+json"> 741 { 742 "@context": "https://schema.org", 743 "@type": "LocalBusiness", 744 "name": "Colorado Visiting Nurse Association", 745 "url": "https://vnacolorado.org" 746 ,"logo": "https://vnacolorado.org/userfiles/2706/images/cvna_2024_logo.png" 747 ,"image": "https://vnacolorado.org/userfiles/2706/images/cvna_2024_logo.png" 748 ,"contactPoint": { 749 "@type": "ContactPoint", 750 "contactType": "customer service" 751 ,"telephone": "303-698-2121" 752 753 ,"email": "[email protected]" 754 } 755 ,"telephone": "303-698-2121" 756 ,"address": { 757 "@type": "PostalAddress", 758 "addressLocality": "Arvada", 759 "addressRegion": "CO", 760 "postalCode": "80002", 761 "streetAddress": " 6750 W. 52nd Ave. Unit F" 762 ,"addressCountry": "United States" 763 } 764 765 766 767 ,"sameAs": [ 768 "https://www.facebook.com/ColoradoVNA","https://www.linkedin.com/company/visiting-nurse-association-of-colorado" 769 ] 770 771 } 772 </script>
772 773 774 775
775<script type="application/ld+json"> 776 { 777 "@context": "https://schema.org", 778 "@type": "WebSite", 779 "name": "Colorado Visiting Nurse Association", 780 "url": "https://vnacolorado.org" 781 782 } 783 </script>
783 784 785 786 787 788 789 790 791 792 793 794 795 796
796<script type="application/ld+json"> 797 { 798 "@context": "https://schema.org", 799 "@type": "BreadcrumbList", 800 "itemListElement": [ 801 802 { 803 "@type": "ListItem", 804 "position": 1, 805 "name": "Home", 806 "item": "https://vnacolorado.org/" 807 } 808 809 ,{ 810 "@type": "ListItem", 811 "position": 2, 812 "name": "About-Us-drop", 813 "item": "https://vnacolorado.org/About" 814 } 815 816 ,{ 817 "@type": "ListItem", 818 "position": 3, 819 "name": "Community-Partnerships-Companies-Foundations", 820 "item": "https://vnacolorado.org/Community Partnerships, Companies & Foundations" 821 } 822 823 ] 824 } 825 </script>
825</head> 826<body> 827<div class="oms-wrapper"> 828<div class="modal fade" id="omniaMgmtLoginModal" tabindex="-1" aria-labelledby="omniaMgmtLoginModalLabel" aria-hidden="true" data-keyboard="false"> 829<div class="modal-dialog modal-dialog-centered mx-auto"> 830<div class="modal-content"> 831<button type="button" class="btn-close-modal" data-dismiss="modal" aria-label="Close">✕</button> 832<div class="modal-header"> 833<div class="header-inner"> 834<div class="modal-icon"> 835<!-- Person / user icon --> 836<svg viewBox="0 0 24 24"><path d="M20 21v-2a4 4 0 0 0-4-4H8a4 4 0 0 0-4 4v2"/><circle cx="12" cy="7" r="4"/></svg> 837</div> 838<div class="modal-title" id="omniaMgmtLoginModalLabel">Management Login</div> 839<div class="modal-subtitle">Sign in to access your dashboard.</div> 840</div> 841</div> 842<div class="modal-body"> 843<form id="loginForm"> 844<input type="hidden" name="s" id="s" value="2706"> 845<input type="hidden" name="forceLogin" id="forceLogin" value="0"> 846</form> 847<!-- ââ Login Screen âââââââââââââââââââââââââââââââââââââââââ --> 848<div id="loginscreen"> 849<div class="login-field login-username-field"> 850<label for="userName">Username</label> 851<div class="login-input-wrap"> 852<input type="text" name="userName" id="userName" maxlength="50" placeholder="Enter your username" autocomplete="off" form="loginForm"> 853</div> 854</div> 855<div class="login-field login-pw-field"> 856<label for="password">Password</label> 857<div class="login-input-wrap"> 858<input type="password" name="password" id="password" maxlength="20" placeholder="Enter your password" autocomplete="off" form="loginForm"> 859<button type="button" class="login-toggle-pw" onclick="loginTogglePW('password', this)" aria-label="Show password"> 860<svg viewBox="0 0 24 24"><path d="M1 12s4-8 11-8 11 8 11 8-4 8-11 8-11-8-11-8z"/><circle cx="12" cy="12" r="3"/></svg> 861</button> 862</div> 863</div> 864<p class="login-note">Passwords are case sensitive</p> 865</div> 866<!-- ââ Forgot Password Screen ââââââââââââââââââââââââââââââ --> 867<div id="forgotpassscreen" style="display:none;"> 868<button type="button" class="btn-back-login"> 869<svg viewBox="0 0 24 24"><polyline points="15 18 9 12 15 6"/></svg> 870Back to login 871</button> 872<form id="forgotPassForm"> 873<input type="hidden" name="s" id="s2" value="2706"> 874<div class="login-field"> 875<label for="emailField">Email Address</label> 876<div class="login-input-wrap"> 877<input type="text" name="emailField" id="emailField" placeholder="Enter your email address" autocomplete="off"> 878</div> 879</div> 880</form> 881</div> 882<!-- ââ Shared alert area âââââââââââââââââââââââââââââââââââ --> 883<div id="loginAlert" class="login-alert text-center"></div> 884</div> 885<div class="modal-footer"> 886<!-- Login screen buttons --> 887<div id="loginFooterBtns" style="width:100%;display:flex;flex-direction:column;gap:10px;"> 888<button type="button" id="loginSubmitted" class="btn-login"> 889<i class="fas fa-sign-in-alt" style="margin-right:7px;"></i>Login 890</button> 891<button type="button" class="btn-forgot forgotUorP">Forgot Password?</button> 892</div> 893<!-- Forgot screen button --> 894<div id="forgotFooterBtns" style="width:100%;display:none;"> 895<button type="button" id="submitRetrievePassword" class="btn-login">Send Reset Email</button> 896</div> 897</div> 898</div> 899</div> 900</div>
901<script> 902// Toggle footer buttons when switching screens 903$(document).ready(function(){ 904$('.forgotUorP').on('click', function(){ 905$('#loginFooterBtns').hide(); 906$('#forgotFooterBtns').show(); 907}); 908$('.btn-back-login').on('click', function(){ 909$('#loginFooterBtns').show(); 910$('#forgotFooterBtns').hide(); 911}); 912}); 913</script>
913 914<header class="omsHeader"> 915</header> 916<style type="text/css">@media (max-width: 991px) { 917.omsNav .navbar-nav, 918.omsNav .dropdown-menu { 919text-align: center; 920font-size: 1.2rem; 921} 922.navbar-collapse { 923text-align: center; 924} 925.omsNav .nav a { 926white-space: break-spaces; 927} 928} 929@media (min-width: 992px) { 930.navbar-expand-lg .navbar-nav .nav-link { 931padding-right: .8rem; 932padding-left: .8rem; 933} 934} 935.omsLogo img { 936width: 120px; 937height: auto !important; 938} 939@media (min-width: 1200px) { 940.omsLogo img { 941width: 200px; 942} 943.navbar-expand-lg .navbar-nav .nav-link { 944padding-right: 1.25rem; 945padding-left: 1.25rem; 946font-size: 1rem; 947} 948} 949@media (min-width: 1600px) { 950.omsLogo img { 951width: 200px; 952} 953.navbar-expand-lg .navbar-nav .nav-link { 954padding-right: 1.5rem; 955padding-left: 1.5rem; 956font-size: 1.1rem; 957} 958} 959.omsNav .navbar-wrapper a:not(.btn):hover { 960color: var(--primary) !important; 961} 962</style> 963<div class="omsNav fixed-top navbar-light bg-white shadow" data-id="5" data-original-title="" style="" title=""> 964<div class="pre-nav bg-dark text-light py-1 small" data-original-title="" title=""> 965<div class="container d-flex justify-content-between align-items-center" data-original-title="" title=""> 966<div class="left" data-original-title="" title=""><a class="mr-3 text-light" data-original-title="" href="tel:303-698-2121" title=""><i class="fas fa-phone text-primary-alt fa-fw mr-1"></i>Call<span class="d-none d-sm-inline-block" data-original-title="" title="">: 303-698-2121</span></a> <a class="mr-3 text-light" data-original-title="" href="mailto:[email protected]" title=""><i class="fas fa-envelope text-primary-alt fa-fw mr-1"></i><span class="d-none d-lg-inline-block" data-original-title="" title="">Send Us an</span> Email</a></div> 967<div class="right" data-original-title="" title=""><!--<a class="ml-3 text-light" href="/contact" title=""><i class="fas fa-star text-primary-alt fa-fw mr-1"></i>Another Button</a>--> 968<div class="socials d-none d-sm-inline-block ml-2 pl-2 border-left" data-original-title="" title=""><a class="ml-1 social-facebook" data-original-title="" href="https://www.facebook.com/ColoradoVNA" target="_blank" title=""><i class="fab fa-facebook-square fa-fw text-light"></i></a> <a class="ml-1 social-instagram" data-original-title="" href="" target="_blank" title=""><i class="fab fa-instagram fa-fw text-light"></i></a> <a class="ml-1 social-yelp" data-original-title="" href="" target="_blank" title=""><i class="fab fa-yelp fa-fw text-light"></i></a> <a class="ml-1 social-tripadvisor" data-original-title="" href="" target="_blank" title=""><i class="fab fa-tripadvisor fa-fw text-light"></i></a> <a class="ml-1 social-twitter" data-original-title="" href="" target="_blank" title=""><i class="fab fa-twitter fa-fw text-light"></i></a> <a class="ml-1 social-linkedin" data-original-title="" href="https://www.linkedin.com/company/visiting-nurse-association-of-colorado" target="_blank" title=""><i class="fab fa-linkedin fa-fw text-light"></i></a> <a class="ml-1 social-pinterest" data-original-title="" href="" target="_blank" title=""><i class="fab fa-pinterest fa-fw text-light"></i></a> <a class="ml-1 social-youtube" data-original-title="" href="" target="_blank" title=""><i class="fab fa-youtube-square fa-fw text-light"></i></a> <a class="mr-3 text-light" data-link="" data-original-title="" data-target="" data-toggle="" href="https://square.link/u/943NdTFo" target="_blank" title=""><i class="text-primary-alt fa-fw mr-1 fas fa-dollar-sign" fa-data=""></i><span class="d-none d-lg-inline-block" data-original-title="" title="">Pay Your Bill</span></a></div> 969</div> 970</div> 971</div> 972<nav class="navbar navbar-expand-lg px-0"> 973<div class="container navbar-wrapper px-3" data-original-title="" title=""> 974<div class="d-flex align-items-center" data-original-title="" title=""><a class="navbar-brand omsLogo" data-original-title="" href="/Home" style="position: relative;" title=""><img alt='Colorado Visiting Nurse Association logo' class='img-fluid' src='/userfiles/2706/images/cvna_2024_logo.png'></a></div> 975<button aria-controls="omsDefaultNav" aria-expanded="false" aria-label="Toggle navigation" class="navbar-toggler collapsed p-2 ml-3" data-target="#omsDefaultNav" data-toggle="collapse" type="button"><i class="fas fa-bars fa-2x fa-fw d-flex align-items-center justify-content-center text-primary" style="font-size: 1.75rem; width: 30px; height: 30px;"></i></button> 976<div class="collapse navbar-collapse ml-md-4" data-original-title="" id="omsDefaultNav" style="justify-content: flex-end; min-height: auto;" title=""><ul class="nav navbar-nav"> 977<li class="nav-item dropdown"><!--nav-item dropdown class to li----> 978<a class="nav-link dropdown-toggle" href="javascript: void(0)" aria-haspopup="true" aria-expanded="false" data-toggle="dropdown" data-level="1">About</a> 979<div class="dropdown-menu"> 980<a class="dropdown-item" href="//vnacolorado.org/about-us" data-level="2">Overview</a> 981<a class="dropdown-item" href="//vnacolorado.org/Community-Partnerships-Companies-Foundations" data-level="2">Community Partnerships, Companies & Foundations</a> 982<a class="dropdown-item" href="//vnacolorado.org/Privacy-Practices-and-Medical-Records" data-level="2">Privacy Practices and Medical Records</a> 983<a class="dropdown-item" href="//vnacolorado.org/Annual-Reports" data-level="2">Annual Reports</a> 984</div> 985</li> 986<li class="nav-item dropdown"><!--nav-item dropdown class to li----> 987<a class="nav-link dropdown-toggle" href="javascript: void(0)" aria-haspopup="true" aria-expanded="false" data-toggle="dropdown" data-level="1">Services</a> 988<div class="dropdown-menu"> 989<a class="dropdown-item" href="//vnacolorado.org/CAPABLE-Community-Aging-in-Place-Advancing-Better-Living-for-Elders" data-level="2">CAPABLE: Community Aging in Place â Advancing Better Living for Elders</a> 990<a class="dropdown-item" href="//vnacolorado.org/Medical-Foot-Care" data-level="2">Medical Foot Care</a> 991<a class="dropdown-item" href="//vnacolorado.org/services" data-level="2">Overview</a> 992</div> 993</li> 994<li class="nav-item"><!--nav-item dropdown class to li----> 995<a class="nav-link" href="//vnacolorado.org/donate" data-level="1">Donate</a> 996</li> 997<li class="nav-item"><!--nav-item dropdown class to li----> 998<a class="nav-link" href="//vnacolorado.org/volunteer" data-level="1">Volunteer</a> 999</li> 1000<li class="nav-item dropdown"><!--nav-item dropdown class to li----> 1001<a class="nav-link dropdown-toggle" href="javascript: void(0)" aria-haspopup="true" aria-expanded="false" data-toggle="dropdown" data-level="1">Join Our Team</a> 1002<div class="dropdown-menu"> 1003<a class="dropdown-item" href="//vnacolorado.org/join-our-team" data-level="2">Join Now</a> 1004<a class="dropdown-item" href="//vnacolorado.org/Nursing-Assistant-Training" data-level="2">Nursing Assistant Training</a> 1005</div> 1006</li> 1007<li class="nav-item"><!--nav-item dropdown class to li----> 1008<a class="nav-link" href="//vnacolorado.org/contact-us" data-level="1">Contact</a> 1009</li> 1010</ul> <!--<a class="btn btn-primary ml-auto mr-auto mr-lg-0 ml-lg-4 my-3 my-lg-0" href="/contact" data-original-title="" title=""><i class="fas fa-star"></i> Another Button</a>--></div> 1011</div> 1012</nav> 1013</div> 1014<!-- Wrapper --> 1015<div class="wrapper wrapper-home wrapper-"> 1016<div id="savecontent"> 1017<section class="snipOuter py-4 py-md-5 py-lg-6 py-xl-8 sub-hero position-relative" data-id="412" id="oms_412" style="background-image: url(/userfiles/2706/images/subhero.jpg); background-size: cover; background-repeat: no-repeat; background-position: center top;"> 1018<div class="wow fadeIn animated" data-original-title="" style="visibility: visible; animation-name: fadeIn;" title=""> 1019<div class="overlay opacity-5 bg-black" data-original-title="" data-wow-delay=".2s" title=""> </div> 1020</div> 1021<div class="text-white container text-light snip text-center wow fadeIn py-5 animated" data-original-title="" data-wow-delay=".2s"> 1022<h1 class="text-white mega position-relative mb-0 font-weight-bold">Community Partnerships, Companies & Foundations</h1> 1023</div> 1024</section> 1025<section class="snipOuter py-4 block-cards" data-id="406" id="oms_406"> 1026<style data-id="406" type="text/css">@media (max-width: 991px) { 1027.block-cards .half-hero { 1028padding-bottom: 70%; 1029} 1030} 1031.block-cards .container .row:nth-of-type(even) .round { 1032flex-direction: row-reverse !important; 1033} 1034@media (min-width: 1600px) { 1035.block-cards .half-text {
1036padding: 5rem !important; 1037} 1038} 1039.block-cards .round .half-text { 1040border-radius: 0; 1041padding-right: 0 !important; 1042} 1043.block-cards .round { 1044border-radius: 0 !important; 1045} 1046</style> 1047<div class="container container-wide snip" data-btn-all="" data-original-title="" title=""> 1048<div class="row no-gutters count py-3 py-lg-4 count round w-100" data-original-title="" style="overflow: hidden;" title=""> 1049<div class="round d-flex flex-row flex-wrap w-100" data-original-title="" style="overflow: hidden;" title=""> 1050<div class="col-12 col-lg-6 half-hero" data-original-title="" style="background-image: url(/userfiles/2706/images/about3.jpg); background-size: cover; background-position: center center; background-repeat: no-repeat; position: relative; display: block;" title=""><span data-original-title="" style="color:var(--primary);" title=""></span></div> 1051<div class="col-12 col-lg-6 p-4 p-sm-4 p-md-5 p-lg-4 p-xl-5 half-text bg-white" data-original-title="" title=""> 1052<h3><span data-original-title="" style="color:var(--dark);" title=""><strong><span data-original-title="" title=""></span></strong></span></h3> 1053<h3><strong>Caring for our Community</strong></h3> 1054<h6>Colorado Visiting Nurse Association provides high-quality health care for seniors and aging patients across the Denver metro area and surrounding areas. </h6> 1055<p> </p> 1056</div> 1057</div> 1058</div> 1059</div> 1060</section> 1061<section class="snipOuter pb-4 pb-lg-5" id="oms_0"> 1062<div class="container snip" data-original-title="" title=""> 1063<div class="round p-3 p-sm-4 p-lg-5 bg-white" data-original-title="" style="border: 3px solid var(--primary);" title=""> 1064<h6 class="mb-0"><strong>âCommunity support and grant funding play a vital role in our ability to meet the healthcare needs of lower-income people, especially the elderly who have limited or fixed incomes and are often forgotten. Colorado Visiting Nurse Association is so grateful to our donors and the foundation community for their understanding and support of this very special population.â</strong></h6> 1065</div> 1066</div> 1067</section> 1068<section class="snipOuter py-4 py-lg-5" id="oms_0"> 1069<div class="container snip" data-original-title="" title=""> 1070<div class="round p-3 p-sm-4 p-lg-5 bg-white" data-original-title="" style="border: 3px solid var(--primary);" title=""> 1071<h6 class="mb-0"><strong>Colorado Visiting Nurse Association is a not-for-profit, 501 (c) (3) charity. All donations we receive are tax-exempt to the full extent allowed by law.</strong></h6> 1072</div> 1073</div> 1074</section> 1075<section class="snipOuter pb-4 pb-lg-5" id="oms_0"> 1076<div class="container snip" data-btn-all="" data-original-title="" title=""> 1077<h4><strong>Companies & Foundations</strong></h4> 1078<p>Partners are critical to Colorado VNAâs work. Financial investments in our operations ensure a secure foundation while directed grants help us address specific community needs. Colorado VNA also partners with area hospitals and universities to conduct grant-supported research.</p> 1079<h6><strong>Current Partners</strong></h6> 1080<ul class="twos"> 1081<li>Boulder County Area Agency on Aging</li> 1082<li>Brotherâs Redevelopment Inc.</li> 1083<li>CAPABLE National Center</li> 1084<li>Colorado PACE</li> 1085<li>Denver Regional Council of Governments</li> 1086<li>Habitat for Humanity of Metro Denver</li> 1087<li>Kaiser Permanente</li> 1088<li>Pikes Peak Habitat for Humanity</li> 1089<li>State of Colorado HCPF</li> 1090</ul> 1091</div> 1092</section> 1093<style type="text/css">/* Tablet and up */ 1094@media (min-width: 768px) { 1095.twos { 1096column-count: 2; 1097column-gap: 1.5rem; 1098/* adjust spacing */ 1099} 1100} 1101</style> 1102</div> 1103</div> <!-- / .wrapper --> 1104<!-- daldals --> 1105<!-- Modal --> 1106<div aria-hidden="true" aria-labelledby="exampleModalLabel" class="modal fade" data-original-title="" id="adultintake" tabindex="-1" title=""> 1107<div class="modal-dialog" data-original-title="" title=""> 1108<div class="modal-content" data-original-title="" title=""> 1109<div class="modal-header bg-light" data-original-title="" title=""> 1110<h5 class="modal-title m-0 font-weight-bold" id="exampleModalLabel">Adult Intake Form</h5> 1111<button aria-label="Close" class="close" data-dismiss="modal" type="button"><span aria-hidden="true" data-original-title="" title="">
1111Ã</span></button></div> 1112<div class="modal-body small p-md-4" data-original-title="" title=""> 1113<div data-original-title="" title=""> 1114<p>Please fill out the form below and a representative will will get in touch with you soon.</p> 1115</div> 1116<hr><style> @media screen and (max-width: 500px){ ##rc-imageselect, .g-recaptcha {transform:scale(0.77);-webkit-transform:scale(0.77);transform-origin:0 0;-webkit-transform-origin:0 0;} } </style> 1117<form role="form" id="tForm_1366"method="post" enctype="multipart/form-data" action="/submitForm_v2.cfm"> 1118<input type="hidden" name="formsc" id="formsc_1366" value="CUSTFORM_R62V487N"> 1119<input type="hidden" name="capval" id="capval_1366" value="76E262DD86DF9626AF9FEA9CB4FD9CC80383B294AC3F"> 1120<input type="hidden" name="honeypot" id="honeypot_1366"> 1121<input type="hidden" name="submitForm" value="submitForm"> 1122<input type="hidden" name="internalSource" value="https://vnacolorado.org?pagetitle=Community-Partnerships-Companies-Foundations"> 1123<input type="hidden" name="userIP" value="81.16.3.32"> 1124<input type="hidden" name="source" id="source_1366_1366" value="Direct"> 1125<input type="hidden" name="status" id="status_1366_1366" value="0"> 1126<div class="formbuilder-text form-group field-FIRSTNAME form-group-1 "> 1127<label for="FIRSTNAME" class="formbuilder-text-label">First Name<span class="formbuilder-required">*</span> 1128</label> 1129<input type="text" placeholder="" class="form-control" name="FIRSTNAME" id="FIRSTNAME" required="required" aria-required="true"> 1130</div> 1131<div class="formbuilder-text form-group field-LASTNAME form-group-2 "> 1132<label for="LASTNAME" class="formbuilder-text-label">Last Name 1133</label> 1134<input type="text" placeholder="" class="form-control" name="LASTNAME" id="LASTNAME" > 1135</div> 1136<div class="formbuilder-text form-group field-STREETADDRESS form-group-3 "> 1137<label for="STREETADDRESS" class="formbuilder-text-label">Address<span class="formbuilder-required">*</span> 1138</label> 1139<input type="text" placeholder="" class="form-control" name="STREETADDRESS" id="STREETADDRESS" required="required" aria-required="true"> 1140</div> 1141<div class="formbuilder-text form-group field-CITY form-group-4 "> 1142<label for="CITY" class="formbuilder-text-label">City<span class="formbuilder-required">*</span> 1143</label> 1144<input type="text" placeholder="" class="form-control" name="CITY" id="CITY" required="required" aria-required="true"> 1145</div> 1146<div class="formbuilder-select form-group field-STATE form-group-5 "> 1147<label for="STATE" class="formbuilder-select-label">State<span class="formbuilder-required">*</span></label> 1148<select class="form-control" name="STATE" access="false" id="STATE" required="required" aria-required="true"> 1149<option value="AL" id="STATE-1">Alabama</option> 1150<option value="AK" id="STATE-2">Alaska</option> 1151<option value="AZ" id="STATE-3">Arizona</option> 1152<option value="AR" id="STATE-4">Arkansas</option> 1153<option value="CA" id="STATE-5">California</option> 1154<option value="CO" id="STATE-6">Colorado</option> 1155<option value="CT" id="STATE-7">Connecticut</option> 1156<option value="DE" id="STATE-8">Delaware</option> 1157<option value="DC" id="STATE-9">District Of Columbia</option> 1158<option value="FL" id="STATE-10">Florida</option> 1159<option value="GA" id="STATE-11">Georgia</option> 1160<option value="HI" id="STATE-12">Hawaii</option> 1161<option value="ID" id="STATE-13">Idaho</option> 1162<option value="IL" id="STATE-14">Illinois</option> 1163<option value="IN" id="STATE-15">Indiana</option> 1164<option value="IA" id="STATE-16">Iowa</option> 1165<option value="KS" id="STATE-17">Kansas</option> 1166<option value="KY" id="STATE-18">Kentucky</option> 1167<option value="LA" id="STATE-19">Louisiana</option> 1168<option value="ME" id="STATE-20">Maine</option> 1169<option value="MD" id="STATE-21">Maryland</option> 1170<option value="MA" id="STATE-22">Massachusetts</option> 1171<option value="MI" id="STATE-23">Michigan</option> 1172<option value="MN" id="STATE-24">Minnesota</option> 1173<option value="MS" id="STATE-25">Mississippi</option> 1174<option value="MO" id="STATE-26">Missouri</option> 1175<option value="MT" id="STATE-27">Montana</option> 1176<option value="NE" id="STATE-28">Nebraska</option> 1177<option value="NV" id="STATE-29">Nevada</option> 1178<option value="NH" id="STATE-30">New Hampshire</option> 1179<option value="NJ" id="STATE-31">New Jersey</option> 1180<option value="NM" id="STATE-32">New Mexico</option> 1181<option value="NY" id="STATE-33">New York</option> 1182<option value="NC" id="STATE-34">North Carolina</option> 1183<option value="ND" id="STATE-35">North Dakota</option> 1184<option value="OH" id="STATE-36">Ohio</option> 1185<option value="OK" id="STATE-37">Oklahoma</option> 1186<option value="OR" id="STATE-38">Oregon</option> 1187<option value="PA" id="STATE-39">Pennsylvania</option> 1188<option value="RI" id="STATE-40">Rhode Island</option> 1189<option value="SC" id="STATE-41">South Carolina</option> 1190<option value="SD" id="STATE-42">South Dakota</option> 1191<option value="TN" id="STATE-43">Tennessee</option> 1192<option value="TX" id="STATE-44">Texas</option> 1193<option value="UT" id="STATE-45">Utah</option> 1194<option value="VT" id="STATE-46">Vermont</option> 1195<option value="VA" id="STATE-47">Virginia</option> 1196<option value="WA" id="STATE-48">Washington</option> 1197<option value="WV" id="STATE-49">West Virginia</option> 1198<option value="WI" id="STATE-50">Wisconsin</option> 1199<option value="WY" id="STATE-51">Wyoming</option> 1200</select> 1201</div> 1202<div class="formbuilder-text form-group field-ZIP form-group-6 "> 1203<label for="ZIP" class="formbuilder-text-label">Zip 1204</label> 1205<input type="text" placeholder="" class="form-control" name="ZIP" id="ZIP" > 1206</div> 1207<div class="formbuilder-text form-group field-PHONENUMBER form-group-7 "> 1208<label for="PHONENUMBER" class="formbuilder-text-label">Home Phone 1209</label> 1210<input type="text" placeholder="" class="form-control" name="PHONENUMBER" id="PHONENUMBER" > 1211</div> 1212<div class="formbuilder-text form-group field-text1771888071702 form-group-8 "> 1213<label for="text1771888071702" class="formbuilder-text-label">Work Phone 1214</label> 1215<input type="text" placeholder="" class="form-control" name="text1771888071702" id="text1771888071702" > 1216</div> 1217<div class="formbuilder-text form-group field-MOBILE form-group-9 "> 1218<label for="MOBILE" class="formbuilder-text-label">Mobile Phone 1219</label> 1220<input type="text" placeholder="" class="form-control" name="MOBILE" id="MOBILE" > 1221</div> 1222<div class="formbuilder-radio-group form-group field-radiogroup1771888103440 form-group-10 "> 1223<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Is it OK to leave a message?</label> 1224<div class="radio-group"> 1225<div class="formbuilder-radio"> 1226<input name="radiogroup1771888103440" access="false" id="radiogroup1771888103440-1" value="Yes" type="radio" > 1227<label for="radiogroup1771888103440-1">Yes</label> 1228</div> 1229<div class="formbuilder-radio"> 1230<input name="radiogroup1771888103440" access="false" id="radiogroup1771888103440-2" value="No" type="radio" > 1231<label for="radiogroup1771888103440-2">No</label> 1232</div> 1233</div> 1234</div> 1235<div class="formbuilder-radio-group form-group field-radiogroup1771888155534 form-group-11 "> 1236<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Is it OK to use texting for appointment scheduling/confirmations?</label> 1237<div class="radio-group"> 1238<div class="formbuilder-radio"> 1239<input name="radiogroup1771888155534" access="false" id="radiogroup1771888155534-1" value="Yes2" type="radio" > 1240<label for="radiogroup1771888155534-1">Yes</label> 1241</div> 1242<div class="formbuilder-radio"> 1243<input name="radiogroup1771888155534" access="false" id="radiogroup1771888155534-2" value="No2" type="radio" > 1244<label for="radiogroup1771888155534-2">No</label> 1245</div> 1246</div> 1247</div> 1248<div class="formbuilder-text form-group field-EMAILADDRESS form-group-12 "> 1249<label for="EMAILADDRESS" class="formbuilder-text-label">Email Address<span class="formbuilder-required">*</span> 1250</label> 1251<input type="email" placeholder="" class="form-control" name="EMAILADDRESS" id="EMAILADDRESS" required="required" aria-required="true"> 1252</div> 1253<div class="formbuilder-date form-group field-DOB form-group-13 "> 1254<label for="DOB" class="formbuilder-date-label">Date Of Birth</label> 1255<input type="date" class="form-control" name="DOB" id="DOB" > 1256</div> 1257<div class="formbuilder-text form-group field-text1771888198076 form-group-14 "> 1258<label for="text1771888198076" class="formbuilder-text-label">Age 1259</label> 1260<input type="text" placeholder="" class="form-control" name="text1771888198076" id="text1771888198076" > 1261</div> 1262<div class="formbuilder-text form-group field-text1771888220893 form-group-15 "> 1263<label for="text1771888220893" class="formbuilder-text-label">Emergency Contact First Name 1264</label> 1265<input type="text" placeholder="" class="form-control" name="text1771888220893" id="text1771888220893" > 1266</div> 1267<div class="formbuilder-text form-group field-text1771888235349 form-group-16 "> 1268<label for="text1771888235349" class="formbuilder-text-label">Emergency Contact Last Name 1269</label> 1270<input type="text" placeholder="" class="form-control" name="text1771888235349" id="text1771888235349" > 1271</div> 1272<div class="formbuilder-text form-group field-text1771888243420 form-group-17 "> 1273<label for="text1771888243420" class="formbuilder-text-label">Relationship 1274</label> 1275<input type="text" placeholder="" class="form-control" name="text1771888243420" id="text1771888243420" > 1276</div> 1277<div class="formbuilder-text form-group field-text1771888252661 form-group-18 "> 1278<label for="text1771888252661" class="formbuilder-text-label">Phone Number 1279</label> 1280<input type="text" placeholder="" class="form-control" name="text1771888252661" id="text1771888252661" > 1281</div> 1282<div class="formbuilder-text form-group field-text-1771888314414 form-group-19 "> 1283<label for="text-1771888314414" class="formbuilder-text-label">First Name of Deceased 1284</label> 1285<input type="text" placeholder="" class="form-control" name="text-1771888314414" id="text-1771888314414" > 1286</div> 1287<div class="formbuilder-text form-group field-text-1771888332028 form-group-20 "> 1288<label for="text-1771888332028" class="formbuilder-text-label">Last Name of Deceased 1289</label> 1290<input type="text" placeholder="" class="form-control" name="text-1771888332028" id="text-1771888332028" > 1291</div> 1292<div class="formbuilder-text form-group field-text-1771888340820 form-group-21 "> 1293<label for="text-1771888340820" class="formbuilder-text-label">Relationship to Deceased 1294</label> 1295<input type="text" placeholder="" class="form-control" name="text-1771888340820" id="text-1771888340820" > 1296</div> 1297<div class="formbuilder-date form-group field-date-1771888358074 form-group-22 "> 1298<label for="date-1771888358074" class="formbuilder-date-label">Date of Death</label> 1299<input type="date" class="form-control" name="date-1771888358074" id="date-1771888358074" > 1300</div> 1301<div class="formbuilder-text form-group field-text-1771888368196 form-group-23 "> 1302<label for="text-1771888368196" class="formbuilder-text-label">Age at Death 1303</label> 1304<input type="text" placeholder="" class="form-control" name="text-1771888368196" id="text-1771888368196" > 1305</div> 1306<div class="formbuilder-text form-group field-text-1771888401396 form-group-24 "> 1307<label for="text-1771888401396" class="formbuilder-text-label">Place of Death 1308</label> 1309<input type="text" placeholder="" class="form-control" name="text-1771888401396" id="text-1771888401396" > 1310</div> 1311<div class="formbuilder-text form-group field-text-1771888400780 form-group-25 "> 1312<label for="text-1771888400780" class="formbuilder-text-label">Cause of Death 1313</label> 1314<input type="text" placeholder="" class="form-control" name="text-1771888400780" id="text-1771888400780" > 1315</div> 1316<div class="formbuilder-radio-group form-group field-radiogroup1771888428994 form-group-26 "> 1317<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Was the person who died a hospice patient?</label> 1318<div class="radio-group"> 1319<div class="formbuilder-radio"> 1320<input name="radiogroup1771888428994" access="false" id="radiogroup1771888428994-1" value="Yes3" type="radio" > 1321<label for="radiogroup1771888428994-1">Yes</label> 1322</div> 1323<div class="formbuilder-radio"> 1324<input name="radiogroup1771888428994" access="false" id="radiogroup1771888428994-2" value="No3" type="radio" > 1325<label for="radiogroup1771888428994-2">No</label> 1326</div> 1327</div> 1328</div> 1329<div class="formbuilder-text form-group field-text-1771888453852 form-group-27 "> 1330<label for="text-1771888453852" class="formbuilder-text-label">If yes, please give the name of the hospice. 1331</label> 1332<input type="text" placeholder="" class="form-control" name="text-1771888453852" id="text-1771888453852" > 1333</div> 1334<div class="formbuilder-text form-group field-text-1771888484563 form-group-28 "> 1335<label for="text-1771888484563" class="formbuilder-text-label">Have you experienced any other losses in the past year? 1336</label> 1337<input type="text" placeholder="" class="form-control" name="text-1771888484563" id="text-1771888484563" > 1338</div> 1339<div class="formbuilder-radio-group form-group field-radiogroup1771888764189 form-group-29 "> 1340<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Marital Status:</label> 1341<div class="radio-group"> 1342<div class="formbuilder-radio"> 1343<input name="radiogroup1771888764189" access="false" id="radiogroup1771888764189-1" value="Married" type="radio" > 1344<label for="radiogroup1771888764189-1">Married</label> 1345</div> 1346<div class="formbuilder-radio"> 1347<input name="radiogroup1771888764189" access="false" id="radiogroup1771888764189-2" value="Divorced" type="radio" > 1348<label for="radiogroup1771888764189-2">Divorced</label> 1349</div> 1350<div class="formbuilder-radio"> 1351<input name="radiogroup1771888764189" access="false" id="radiogroup1771888764189-3" value="Single" t
1351ype="radio" > 1352<label for="radiogroup1771888764189-3">Single</label> 1353</div> 1354<div class="formbuilder-radio"> 1355<input name="radiogroup1771888764189" access="false" id="radiogroup1771888764189-4" value="Widowed" type="radio" > 1356<label for="radiogroup1771888764189-4">Widowed</label> 1357</div> 1358<div class="formbuilder-radio"> 1359<input name="radiogroup1771888764189" access="false" id="radiogroup1771888764189-5" value="Other" type="radio" > 1360<label for="radiogroup1771888764189-5">Other</label> 1361</div> 1362</div> 1363</div> 1364<div class="formbuilder-text form-group field-text-1771888939116 form-group-30 "> 1365<label for="text-1771888939116" class="formbuilder-text-label">Name 1366</label> 1367<input type="text" placeholder="" class="form-control" name="text-1771888939116" id="text-1771888939116" > 1368</div> 1369<div class="formbuilder-text form-group field-text-1771888947188 form-group-31 "> 1370<label for="text-1771888947188" class="formbuilder-text-label">Age 1371</label> 1372<input type="text" placeholder="" class="form-control" name="text-1771888947188" id="text-1771888947188" > 1373</div> 1374<div class="formbuilder-text form-group field-text-1771888946571 form-group-32 "> 1375<label for="text-1771888946571" class="formbuilder-text-label">Relationship 1376</label> 1377<input type="text" placeholder="" class="form-control" name="text-1771888946571" id="text-1771888946571" > 1378</div> 1379<div class="formbuilder-text form-group field-text-1771888972940 form-group-33 "> 1380<label for="text-1771888972940" class="formbuilder-text-label">Name 1381</label> 1382<input type="text" placeholder="" class="form-control" name="text-1771888972940" id="text-1771888972940" > 1383</div> 1384<div class="formbuilder-text form-group field-text-1771888982035 form-group-34 "> 1385<label for="text-1771888982035" class="formbuilder-text-label">Age 1386</label> 1387<input type="text" placeholder="" class="form-control" name="text-1771888982035" id="text-1771888982035" > 1388</div> 1389<div class="formbuilder-text form-group field-text-1771888988460 form-group-35 "> 1390<label for="text-1771888988460" class="formbuilder-text-label">Relationship 1391</label> 1392<input type="text" placeholder="" class="form-control" name="text-1771888988460" id="text-1771888988460" > 1393</div> 1394<div class="formbuilder-text form-group field-text-1771888973508 form-group-36 "> 1395<label for="text-1771888973508" class="formbuilder-text-label">Name 1396</label> 1397<input type="text" placeholder="" class="form-control" name="text-1771888973508" id="text-1771888973508" > 1398</div> 1399<div class="formbuilder-text form-group field-text-1771888981467 form-group-37 "> 1400<label for="text-1771888981467" class="formbuilder-text-label">Age 1401</label> 1402<input type="text" placeholder="" class="form-control" name="text-1771888981467" id="text-1771888981467" > 1403</div> 1404<div class="formbuilder-text form-group field-text-1771888988763 form-group-38 "> 1405<label for="text-1771888988763" class="formbuilder-text-label">Relationship 1406</label> 1407<input type="text" placeholder="" class="form-control" name="text-1771888988763" id="text-1771888988763" > 1408</div> 1409<div class="formbuilder-radio-group form-group field-radiogroup1771889010843 form-group-39 "> 1410<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Are you currently working?</label> 1411<div class="radio-group"> 1412<div class="formbuilder-radio"> 1413<input name="radiogroup1771889010843" access="false" id="radiogroup1771889010843-1" value="Yes-work" type="radio" > 1414<label for="radiogroup1771889010843-1">Yes</label> 1415</div> 1416<div class="formbuilder-radio"> 1417<input name="radiogroup1771889010843" access="false" id="radiogroup1771889010843-2" value="No-work" type="radio" > 1418<label for="radiogroup1771889010843-2">No</label> 1419</div> 1420</div> 1421</div> 1422<div class="formbuilder-text form-group field-text-1771889038283 form-group-40 "> 1423<label for="text-1771889038283" class="formbuilder-text-label">Please list any mental health concerns/diagnosis: 1424</label> 1425<input type="text" placeholder="" class="form-control" name="text-1771889038283" id="text-1771889038283" > 1426</div> 1427<div class="formbuilder-radio-group form-group field-radiogroup1771889050468 form-group-41 "> 1428<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Are you currently receiving counseling services from another provider?</label> 1429<div class="radio-group"> 1430<div class="formbuilder-radio"> 1431<input name="radiogroup1771889050468" access="false" id="radiogroup1771889050468-1" value="Yes-council" type="radio" > 1432<label for="radiogroup1771889050468-1">Yes</label> 1433</div> 1434<div class="formbuilder-radio"> 1435<input name="radiogroup1771889050468" access="false" id="radiogroup1771889050468-2" value="No-council" type="radio" > 1436<label for="radiogroup1771889050468-2">No</label> 1437</div> 1438</div> 1439</div> 1440<div class="formbuilder-radio-group form-group field-radiogroup1771889075755 form-group-42 "> 1441<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Have you seriously considered or attempted suicide?</label> 1442<div class="radio-group"> 1443<div class="formbuilder-radio"> 1444<input name="radiogroup1771889075755" access="false" id="radiogroup1771889075755-1" value="Yes-suicide" type="radio" > 1445<label for="radiogroup1771889075755-1">Yes</label> 1446</div> 1447<div class="formbuilder-radio"> 1448<input name="radiogroup1771889075755" access="false" id="radiogroup1771889075755-2" value="No-suicide" type="radio" > 1449<label for="radiogroup1771889075755-2">No</label> 1450</div> 1451</div> 1452</div> 1453<div class="formbuilder-radio-group form-group field-radiogroup1771889075339 form-group-43 "> 1454<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">
1454Have you been hospitalized for physical/mental health reasons within the last 5 years?</label> 1455<div class="radio-group"> 1456<div class="formbuilder-radio"> 1457<input name="radiogroup1771889075339" access="false" id="radiogroup1771889075339-1" value="Yes-hospital" type="radio" > 1458<label for="radiogroup1771889075339-1">Yes</label> 1459</div> 1460<div class="formbuilder-radio"> 1461<input name="radiogroup1771889075339" access="false" id="radiogroup1771889075339-2" value="No-hospital" type="radio" > 1462<label for="radiogroup1771889075339-2">No</label> 1463</div> 1464</div> 1465</div> 1466<div class="formbuilder-textarea form-group field-COMMENTS form-group-44 "> 1467<label for="textarea-COMMENTS" class="formbuilder-textarea-label">Please list any current medical conditions:</label> 1468<textarea type="textarea" class="form-control" name="COMMENTS" access="false" id="COMMENTS" ></textarea> 1469</div> 1470<div class="formbuilder-textarea form-group field-textarea-1771889149659 form-group-45 "> 1471<label for="textarea-textarea-1771889149659" class="formbuilder-textarea-label">Please list any current medications you are taking:</label> 1472<textarea type="textarea" class="form-control" name="textarea-1771889149659" access="false" id="textarea-1771889149659" ></textarea> 1473</div> 1474<div class="formbuilder-radio-group form-group field-radiogroup1771889127947 form-group-46 "> 1475<label for="radiogroup1624396622010" class="formbuilder-radiogrouplabel">Have you ever abused drugs or alcohol?</label> 1476<div class="radio-group"> 1477<div class="formbuilder-radio"> 1478<input name="radiogroup1771889127947" access="false" id="radiogroup1771889127947-1" value="Yes-drugs" type="radio" > 1479<label for="radiogroup1771889127947-1">Yes</label> 1480</div> 1481<div class="formbuilder-radio"> 1482<input name="radiogroup1771889127947" access="false" id="radiogroup1771889127947-2" value="No-drugs" type="radio" > 1483<label for="radiogroup1771889127947-2">No</label> 1484</div> 1485</div> 1486</div> 1487<div class="formbuilder-checkbox-group form-group field-checkboxgroup1771889217916 form-group-47 "> 1488<label for="checkboxgroup1771889217916" class="formbuilder-checkboxgrouplabel">People who are grieving may experience any of the following symptoms. Do any of these apply to you?</label> 1489<div class="checkbox-group"> 1490<div class="formbuilder-checkbox"> 1491<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-1" value=" Irritability" type="checkbox" ><label for="checkboxgroup1771889217916-1"> Irritability</label> 1492</div> 1493<div class="formbuilder-checkbox"> 1494<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-2" value="appetite" type="checkbox" ><label for="checkboxgroup1771889217916-2">Change in appetite</label> 1495</div> 1496<div class="formbuilder-checkbox"> 1497<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-3" value="Loneliness" type="checkbox" ><label for="checkboxgroup1771889217916-3">Loneliness</label> 1498</div> 1499<div class="formbuilder-checkbox"> 1500<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-4" value="Restlessness" type="checkbox" ><label for="checkboxgroup1771889217916-4">Restlessness</label> 1501</div> 1502<div class="formbuilder-checkbox"> 1503<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-5" value="worry" type="checkbox" ><label for="checkboxgroup1771889217916-5">Excessive worry</label> 1504</div> 1505<div class="formbuilder-checkbox"> 1506<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-6" value="Sexual" type="checkbox" ><label for="checkboxgroup1771889217916-6">Sexual problems</label> 1507</div> 1508<div class="formbuilder-checkbox"> 1509<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-7" value="energy" type="checkbox" ><label for="checkboxgroup1771889217916-7">Decreased energy</label> 1510</div> 1511<div class="formbuilder-checkbox"> 1512<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-8" value="Fatigue" type="checkbox" ><label for="checkboxgroup1771889217916-8">Fatigue</label> 1513</div> 1514<div class="formbuilder-checkbox"> 1515<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-9" value="Insomnia" type="checkbox" ><label for="checkboxgroup1771889217916-9">Nightmares/Insomnia</label> 1516</div> 1517<div class="formbuilder-checkbox"> 1518<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-10" value="Hallucinations" type="checkbox" ><label for="checkboxgroup1771889217916-10">Hallucinations</label> 1519</div> 1520<div class="formbuilder-checkbox"> 1521<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-11" value="guilt" type="checkbox" ><label for="checkboxgroup1771889217916-11">Excessive guilt</label> 1522</div> 1523<div class="formbuilder-checkbox"> 1524<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-12" value="Stress" type="checkbox" ><label for="checkboxgroup1771889217916-12">Tension/Stress</label> 1525</div> 1526<div class="formbuilder-checkbox"> 1527<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-13" value="Confusion" type="checkbox" ><label for="checkboxgroup1771889217916-13">Confusion</label> 1528</div> 1529<div class="formbuilder-checkbox"> 1530<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-14" value="Weight" type="checkbox" ><label for="checkboxgroup1771889217916-14">Weight gain or loss</label> 1531</div> 1532<div class="formbuilder-checkbox"> 1533<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-15" value="Headaches" type="checkbox" ><label for="checkboxgroup1771889217916-15">Headaches</label> 1534</div> 1535<div class="formbuilder-checkbox"> 1536<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-16" value="concentration" type="checkbox" ><label for="checkboxgroup1771889217916-16">Poor concentration</label> 1537</div> 1538<div class="formbuilder-checkbox"> 1539<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-17" value="concentration" type="checkbox" ><label for="checkboxgroup1771889217916-17">Hopelessness</label> 1540</div> 1541<div class="formbuilder-checkbox"> 1542<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-18" value="Health" type="checkbox" ><label for="checkboxgroup1771889217916-18">Health problems</label> 1543</div> 1544<div class="formbuilder-checkbox"> 1545<input name="checkboxgroup1771889217916" access="false" id="checkboxgroup1771889217916-19" value="Alcohol" type="checkbox" ><label for="checkboxgroup1771889217916-19">Alcohol/Substance use</label> 1546</div> 1547</div> 1548</div> 1549<div class="formbuilder-text form-group field-text-1771889411252 form-group-48 "> 1550<label for="text-1771889411252" class="formbuilder-text-label">I understand how grief is affecting me. 1551</label> 1552<input type="text" placeholder="" class="form-control" name="text-1771889411252" id="text-1771889411252" > 1553</div> 1554<div class="formbuilder-text form-group field-text-1771889437683 form-group-49 "> 1555<label for="text-1771889437683" class="formbuilder-text-label">I have tools to cope with my grief effectively. 1556</label> 1557<input type="text" placeholder="" class="form-control" name="text-1771889437683" id="text-1771889437683" > 1558</div> 1559<div class="formbuilder-text form-group field-text-1771889435836 form-group-50 "> 1560<label for="text-1771889435836" class="formbuilder-text-label">I can handle the intense feelings that go with grief (i.e. guilt, anger, fear, sadness). 1561</label> 1562<input type="text" placeholder="" class="form-control" name="text-1771889435836" id="text-1771889435836" > 1563</div> 1564<div class="formbuilder-text form-group field-text-1771889435651 form-group-51 "> 1565<label for="text-1771889435651" class="formbuilder-text-label">I know what kind of support I need in my grief and where to find it. 1566</label> 1567<input type="text" placeholder="" class="form-control" name="text-1771889435651" id="text-1771889435651" > 1568</div> 1569<div class="formbuilder-text form-group field-text-1771889435379 form-group-52 "> 1570<label for="text-1771889435379" class="formbuilder-text-label">I believe that I can go on living and loving even though my loved one is gone. 1571</label> 1572<input type="text" placeholder="" class="form-control" name="text-1771889435379" id="text-1771889435379" > 1573</div> 1574<div class="formbuilder-text form-group field-text-1771889554571 form-group-53 "> 1575<label for="text-1771889554571" class="formbuilder-text-label">
1575Please list any support resources available to you at this time (i.e. friends, family, church, community groups,activities). 1576</label> 1577<input type="text" placeholder="" class="form-control" name="text-1771889554571" id="text-1771889554571" > 1578</div> 1579<div class="formbuilder-text form-group field-text-1771889564124 form-group-54 "> 1580<label for="text-1771889564124" class="formbuilder-text-label">What prompted you to seek grief counseling and what are you hoping to get out of your sessions? 1581</label> 1582<input type="text" placeholder="" class="form-control" name="text-1771889564124" id="text-1771889564124" > 1583</div> 1584<div class="formbuilder-text form-group field-text-1771889563147 form-group-55 "> 1585<label for="text-1771889563147" class="formbuilder-text-label">Anything else you would like your counselor to know about you? 1586</label> 1587<input type="text" placeholder="" class="form-control" name="text-1771889563147" id="text-1771889563147" > 1588</div> 1589<div class="formbuilder-text form-group field-text-1771889562356 form-group-56 "> 1590<label for="text-1771889562356" class="formbuilder-text-label">Where did you hear about CVNA Grief Counseling Services? 1591</label> 1592<input type="text" placeholder="" class="form-control" name="text-1771889562356" id="text-1771889562356" > 1593</div> 1594<div class="formbuilder-checkbox-group form-group field-checkboxgroup1771889615493 form-group-57 "> 1595<label for="checkboxgroup1771889615493" class="formbuilder-checkboxgrouplabel">Location:</label> 1596<div class="checkbox-group"> 1597<div class="formbuilder-checkbox"> 1598<input name="checkboxgroup1771889615493" access="false" id="checkboxgroup1771889615493-1" value="Home" type="checkbox" ><label for="checkboxgroup1771889615493-1">Home</label> 1599</div> 1600<div class="formbuilder-checkbox"> 1601<input name="checkboxgroup1771889615493" access="false" id="checkboxgroup1771889615493-2" value="Office" type="checkbox" ><label for="checkboxgroup1771889615493-2">Counseling Office</label> 1602</div> 1603<div class="formbuilder-checkbox"> 1604<input name="checkboxgroup1771889615493" access="false" id="checkboxgroup1771889615493-3" value="Phone-Video" type="checkbox" ><label for="checkboxgroup1771889615493-3">Phone/Video Counseling</label> 1605</div> 1606</div> 1607</div> 1608<div class="formbuilder-checkbox-group form-group field-checkboxgroup1771889680467 form-group-58 "> 1609<label for="checkboxgroup1771889680467" class="formbuilder-checkboxgrouplabel">Day of week (mark all that apply):</label> 1610<div class="checkbox-group"> 1611<div class="formbuilder-checkbox"> 1612<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-1" value="Monday" type="checkbox" ><label for="checkboxgroup1771889680467-1">Monday</label> 1613</div> 1614<div class="formbuilder-checkbox"> 1615<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-2" value="Tuesday" type="checkbox" ><label for="checkboxgroup1771889680467-2">Tuesday</label> 1616</div> 1617<div class="formbuilder-checkbox"> 1618<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-3" value="Wednesday" type="checkbox" ><label for="checkboxgroup1771889680467-3">Wednesday</label> 1619</div> 1620<div class="formbuilder-checkbox"> 1621<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-4" value="Thursday" type="checkbox" ><label for="checkboxgroup1771889680467-4">Thursday</label> 1622</div> 1623<div class="formbuilder-checkbox"> 1624<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-5" value="Thursday" type="checkbox" ><label for="checkboxgroup1771889680467-5">Friday</label> 1625</div> 1626<div class="formbuilder-checkbox"> 1627<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-6" value="Saturday" type="checkbox" ><label for="checkboxgroup1771889680467-6">Saturday</label> 1628</div> 1629<div class="formbuilder-checkbox"> 1630<input name="checkboxgroup1771889680467" access="false" id="checkboxgroup1771889680467-7" value="Sunday" type="checkbox" ><label for="checkboxgroup1771889680467-7">Sunday</label> 1631</div> 1632</div> 1633</div> 1634<div class="formbuilder-checkbox-group form-group field-checkboxgroup1771889738674 form-group-59 "> 1635<label for="checkboxgroup1771889738674" class="formbuilder-checkboxgrouplabel">Time of day (mark all that apply):</label> 1636<div class="checkbox-group"> 1637<div class="formbuilder-checkbox"> 1638<input name="checkboxgroup1771889738674" access="false" id="checkboxgroup1771889738674-1" value="Morning" type="checkbox" ><label for="checkboxgroup1771889738674-1">Morning</label> 1639</div> 1640<div class="formbuilder-checkbox"> 1641<input name="checkboxgroup1771889738674" access="false" id="checkboxgroup1771889738674-2" value="Afternoon" type="checkbox" ><label for="checkboxgroup1771889738674-2">Afternoon</label> 1642</div> 1643<div class="formbuilder-checkbox"> 1644<input name="checkboxgroup1771889738674" access="false" id="checkboxgroup1771889738674-3" value="Evening" type="checkbox" ><label for="checkboxgroup1771889738674-3">Evening</label> 1645</div> 1646</div> 1647</div> 1648<div class="formbuilder-checkbox-group form-group field-checkboxgroup1771889769075 form-group-60 "> 1649<label for="checkboxgroup1771889769075" class="formbuilder-checkboxgrouplabel">Consent<span class="formbuilder-required">*</span></label> 1650<div class="checkbox-group"> 1651<div class="formbuilder-checkbox"> 1652<input name="checkboxgroup1771889769075" access="false" id="checkboxgroup1771889769075-1" value="consent" type="checkbox" required="required" aria-required="true"><label for="checkboxgroup1771889769075-1">I consent to allow Colorado VNA to collect the information on this form.</label> 1653</div> 1654</div> 1655</div> 1656<div class="oms-captcha"> 1657<div class="form-control text-center"> 1658<img src="/images/numbers/tres.png" class="p-1" style="height: 20px;"><img src="/images/numbers/plus.png" class="p-1" style="height: 20px;"><img src="/images/numbers/siete.png" class="p-1" style="height: 20px;"> 1659</div> 1660</div> 1661<div class="oms-captcha"> 1662<input type="text" name="antispam" id="antispam" class="form-control my-2" maxlength="2" placeholder="Answer the above to help eliminate spam" required=""> 1663</div> 1664<button class="btn btn-primary d-block" name="submitForm" id="submitForm_1366" type="submit">Submit</button> 1665</form> 1666<hr> 1667<p class="small">*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.</p> 1668</div> 1669</div> 1670</div> 1671</div> 1672<!-- Modal --> 1673<div aria-hidden="true" aria-labelledby="exampleModalLabel" class="modal fade" data-original-title="" id="griefsupport" tabindex="-1" title=""> 1674<div class="modal-dialog" data-original-title="" title=""> 1675<div class="modal-content" data-original-title="" title=""> 1676<div class="modal-header bg-light" data-original-title="" title=""> 1677<h5 class="modal-title m-0 font-weight-bold" id="exampleModalLabel">Grief Support Registration</h5> 1678<button aria-label="Close" class="close" data-dismiss="modal" type="button"><span aria-hidden="true" data-original-title="" title="">
1678Ã</span></button></div> 1679<div class="modal-body small p-md-4" data-original-title="" title=""> 1680<div data-original-title="" title=""> 1681<p> 1682A member of the Grief Services staff will contact you to confirm the dates of the next group(s) and to complete your registration. If you have any questions, please call Grief Services at 720-325-2987.</p> 1683</div> 1684<hr><style> @media screen and (max-width: 500px){ ##rc-imageselect, .g-recaptcha {transform:scale(0.77);-webkit-transform:scale(0.77);transform-origin:0 0;-webkit-transform-origin:0 0;} } </style> 1685<form role="form" id="tForm_8407"method="post" enctype="multipart/form-data" action="/submitForm_v2.cfm"> 1686<input type="hidden" name="formsc" id="formsc_8407" value="CUSTFORM_STLJAP48"> 1687<input type="hidden" name="capval" id="capval_8407" value="76E262DD86DF9626AF9FEA9CB4FD9CC80283B294AC3F"> 1688<input type="hidden" name="honeypot" id="honeypot_8407"> 1689<input type="hidden" name="submitForm" value="submitForm"> 1690<input type="hidden" name="internalSource" value="https://vnacolorado.org?pagetitle=Community-Partnerships-Companies-Foundations"> 1691<input type="hidden" name="userIP" value="81.16.3.32"> 1692<input type="hidden" name="source" id="source_8407_8407" value="Direct"> 1693<input type="hidden" name="status" id="status_8407_8407" value="0"> 1694<div class="formbuilder-checkbox-group form-group field-checkboxgroup1772663884976 form-group-1 "> 1695<label for="checkboxgroup1772663884976" class="formbuilder-checkboxgrouplabel">I am interested in attending or knowing more about the following groups/events:</label> 1696<div class="checkbox-group"> 1697<div class="formbuilder-checkbox"> 1698<input name="checkboxgroup1772663884976" access="false" id="checkboxgroup1772663884976-1" value="broom" type="checkbox" ><label for="checkboxgroup1772663884976-1">GROUP - Monday Mournings: Broomfield Daytime Group</label> 1699</div> 1700<div class="formbuilder-checkbox"> 1701<input name="checkboxgroup1772663884976" access="false" id="checkboxgroup1772663884976-2" value="other" type="checkbox" ><label for="checkboxgroup1772663884976-2">Other (One on one counseling is available only for CVNA families)</label> 1702</div> 1703</div> 1704</div> 1705<div class="formbuilder-text form-group field-FIRSTNAME form-group-2 "> 1706<label for="FIRSTNAME" class="formbuilder-text-label">First Name<span class="formbuilder-required">*</span> 1707</label> 1708<input type="text" placeholder="" class="form-control" name="FIRSTNAME" id="FIRSTNAME" required="required" aria-required="true"> 1709</div> 1710<div class="formbuilder-text form-group field-LASTNAME form-group-3 "> 1711<label for="LASTNAME" class="formbuilder-text-label">Last Name 1712</label> 1713<input type="text" placeholder="" class="form-control" name="LASTNAME" id="LASTNAME" > 1714</div> 1715<div class="formbuilder-text form-group field-STREETADDRESS form-group-4 "> 1716<label for="STREETADDRESS" class="formbuilder-text-label">Address 1717</label> 1718<input type="text" placeholder="" class="form-control" name="STREETADDRESS" id="STREETADDRESS" > 1719</div> 1720<div class="formbuilder-text form-group field-CITY form-group-5 "> 1721<label for="CITY" class="formbuilder-text-label">City 1722</label> 1723<input type="text" placeholder="" class="form-control" name="CITY" id="CITY" > 1724</div> 1725<div class="formbuilder-select form-group field-STATE form-group-6 "> 1726<label for="STATE" class="formbuilder-select-label">State</label> 1727<select class="form-control" name="STATE" access="false" id="STATE" > 1728<option value="AL" id="STATE-1">Alabama</option> 1729<option value="AK" id="STATE-2">Alaska</option> 1730<option value="AZ" id="STATE-3">Arizona</option> 1731<option value="AR" id="STATE-4">Arkansas</option> 1732<option value="CA" id="STATE-5">California</option> 1733<option value="CO" id="STATE-6">Colorado</option> 1734<option value="CT" id="STATE-7">Connecticut</option> 1735<option value="DE" id="STATE-8">Delaware</option> 1736<option value="DC" id="STATE-9">District Of Columbia</option> 1737<option value="FL" id="STATE-10">Florida</option> 1738<option value="GA" id="STATE-11">Georgia</option> 1739<option value="HI" id="STATE-12">Hawaii</option> 1740<option value="ID" id="STATE-13">Idaho</option> 1741<option value="IL" id="STATE-14">Illinois</option> 1742<option value="IN" id="STATE-15">Indiana</option> 1743<option value="IA" id="STATE-16">Iowa</option> 1744<option value="KS" id="STATE-17">Kansas</option> 1745<option value="KY" id="STATE-18">Kentucky</option> 1746<option value="LA" id="STATE-19">Louisiana</option> 1747<option value="ME" id="STATE-20">Maine</option> 1748<option value="MD" id="STATE-21">Maryland</option> 1749<option value="MA" id="STATE-22">Massachusetts</option> 1750<option value="MI" id="STATE-23">Michigan</option> 1751<option value="MN" id="STATE-24">Minnesota</option> 1752<option value="MS" id="STATE-25">Mississippi</option> 1753<option value="MO" id="STATE-26">Missouri</option> 1754<option value="MT" id="STATE-27">Montana</option> 1755<option value="NE" id="STATE-28">Nebraska</option> 1756<option value="NV" id="STATE-29">Nevada</option> 1757<option value="NH" id="STATE-30">New Hampshire</option> 1758<option value="NJ" id="STATE-31">New Jersey</option> 1759<option value="NM" id="STATE-32">New Mexico</option> 1760<option value="NY" id="STATE-33">New York</option> 1761<option value="NC" id="STATE-34">North Carolina</option> 1762<option value="ND" id="STATE-35">North Dakota</option> 1763<option value="OH" id="STATE-36">Ohio</option> 1764<option value="OK" id="STATE-37">Oklahoma</option> 1765<option value="OR" id="STATE-38">Oregon</option> 1766<option value="PA" id="STATE-39">Pennsylvania</option> 1767<option value="RI" id="STATE-40">Rhode Island</option> 1768<option value="SC" id="STATE-41">South Carolina</option> 1769<option value="SD" id="STATE-42">South Dakota</option> 1770<option value="TN" id="STATE-43">Tennessee</option> 1771<option value="TX" id="STATE-44">Texas</option> 1772<option value="UT" id="STATE-45">Utah</option> 1773<option value="VT" id="STATE-46">Vermont</option> 1774<option value="VA" id="STATE-47">Virginia</option> 1775<option value="WA" id="STATE-48">Washington</option> 1776<option value="WV" id="STATE-49">West Virginia</option> 1777<option value="WI" id="STATE-50">Wisconsin</option> 1778<option value="WY" id="STATE-51">Wyoming</option> 1779</select> 1780</div> 1781<div class="formbuilder-text form-group field-ZIP form-group-7 "> 1782<label for="ZIP" class="formbuilder-text-label">Zip 1783</label> 1784<input type="text" placeholder="" class="form-control" name="ZIP" id="ZIP" > 1785</div> 1786<div class="formbuilder-text form-group field-text-1772663982909 form-group-8 "> 1787<label for="text-1772663982909" class="formbuilder-text-label">Home Phone 1788</label> 1789<input type="text" placeholder="" class="form-control" name="text-1772663982909" id="text-1772663982909" > 1790</div> 1791<div class="formbuilder-text form-group field-text-1772663985671 form-group-9 "> 1792<label for="text-1772663985671" class="formbuilder-text-label">Work Phone 1793</label> 1794<input type="text" placeholder="" class="form-control" name="text-1772663985671" id="text-1772663985671" > 1795</div> 1796<div class="formbuilder-text form-group field-PHONENUMBER form-group-10 "> 1797<label for="PHONENUMBER" class="formbuilder-text-label">Mobile Phone 1798</label> 1799<input type="text" placeholder="" class="form-control" name="PHONENUMBER" id="PHONENUMBER" > 1800</div> 1801<div class="formbuilder-text form-group field-EMAILADDRESS form-group-11 "> 1802<label for="EMAILADDRESS" class="formbuilder-text-label">Email Address<span class="formbuilder-required">*</span> 1803</label> 1804<input type="email" placeholder="" class="form-control" name="EMAILADDRESS" id="EMAILADDRESS" required="required" aria-required="true"> 1805</div> 1806<div class="formbuilder-checkbox-group form-group field-checkboxgroup1772664033071 form-group-12 "> 1807<label for="checkboxgroup1772664033071" class="formbuilder-checkboxgrouplabel">Preferred Method of Communication (Check all that apply)</label> 1808<div class="checkbox-group"> 1809<div class="formbuilder-checkbox"> 1810<input name="checkboxgroup1772664033071" access="false" id="checkboxgroup1772664033071-1" value="phone" type="checkbox" ><label for="checkboxgroup1772664033071-1">Phone</label> 1811</div> 1812<div class="formbuilder-checkbox"> 1813<input name="checkboxgroup1772664033071" access="false" id="checkboxgroup1772664033071-2" value="text" t
1813ype="checkbox" ><label for="checkboxgroup1772664033071-2">Text</label> 1814</div> 1815<div class="formbuilder-checkbox"> 1816<input name="checkboxgroup1772664033071" access="false" id="checkboxgroup1772664033071-3" value="email" type="checkbox" ><label for="checkboxgroup1772664033071-3">Email</label> 1817</div> 1818</div> 1819</div> 1820<div class="formbuilder-date form-group field-DOB form-group-13 "> 1821<label for="DOB" class="formbuilder-date-label">Date Of Birth</label> 1822<input type="date" class="form-control" name="DOB" id="DOB" > 1823</div> 1824<div class="formbuilder-text form-group field-text-1772664065224 form-group-14 "> 1825<label for="text-1772664065224" class="formbuilder-text-label">Age 1826</label> 1827<input type="text" placeholder="" class="form-control" name="text-1772664065224" id="text-1772664065224" > 1828</div> 1829<div class="formbuilder-text form-group field-text-1772664086256 form-group-15 "> 1830<label for="text-1772664086256" class="formbuilder-text-label">First Name of Deceased 1831</label> 1832<input type="text" placeholder="" class="form-control" name="text-1772664086256" id="text-1772664086256" > 1833</div> 1834<div class="formbuilder-text form-group field-text-1772664094735 form-group-16 "> 1835<label for="text-1772664094735" class="formbuilder-text-label">Last Name of Deceased 1836</label> 1837<input type="text" placeholder="" class="form-control" name="text-1772664094735" id="text-1772664094735" > 1838</div> 1839<div class="formbuilder-text form-group field-text-1772664093983 form-group-17 "> 1840<label for="text-1772664093983" class="formbuilder-text-label">Relationship to Deceased 1841</label> 1842<input type="text" placeholder="" class="form-control" name="text-1772664093983" id="text-1772664093983" > 1843</div> 1844<div class="formbuilder-date form-group field-date-1772664104864 form-group-18 "> 1845<label for="date-1772664104864" class="formbuilder-date-label">Date of Death</label> 1846<input type="date" class="form-control" name="date-1772664104864" id="date-1772664104864" > 1847</div> 1848<div class="formbuilder-text form-group field-text-1772664093279 form-group-19 "> 1849<label for="text-1772664093279" class="formbuilder-text-label">Age at Death 1850</label> 1851<input type="text" placeholder="" class="form-control" name="text-1772664093279" id="text-1772664093279" > 1852</div> 1853<div class="formbuilder-text form-group field-text-1772664092567 form-group-20 "> 1854<label for="text-1772664092567" class="formbuilder-text-label">Place of Death 1855</label> 1856<input type="text" placeholder="" class="form-control" name="text-1772664092567" id="text-1772664092567" > 1857</div> 1858<div class="formbuilder-text form-group field-text-1772664091999 form-group-21 "> 1859<label for="text-1772664091999" class="formbuilder-text-label">Cause of Death 1860</label> 1861<input type="text" placeholder="" class="form-control" name="text-1772664091999" id="text-1772664091999" > 1862</div> 1863<div class="formbuilder-checkbox-group form-group field-checkboxgroup1772664176576 form-group-22 "> 1864<label for="checkboxgroup1772664176576" class="formbuilder-checkboxgrouplabel">Were they a CVNA hospice patient?</label> 1865<div class="checkbox-group"> 1866<div class="formbuilder-checkbox"> 1867<input name="checkboxgroup1772664176576" access="false" id="checkboxgroup1772664176576-1" value="yes" type="checkbox" ><label for="checkboxgroup1772664176576-1">Yes</label> 1868</div> 1869<div class="formbuilder-checkbox"> 1870<input name="checkboxgroup1772664176576" access="false" id="checkboxgroup1772664176576-2" value="no" type="checkbox" ><label for="checkboxgroup1772664176576-2">No</label> 1871</div> 1872</div> 1873</div> 1874<div class="formbuilder-textarea form-group field-COMMENTS form-group-23 "> 1875<label for="textarea-COMMENTS" class="formbuilder-textarea-label">Have you experienced any other losses in the past year?</label> 1876<textarea type="textarea" class="form-control" name="COMMENTS" access="false" id="COMMENTS" ></textarea> 1877</div> 1878<div class="formbuilder-text form-group field-text-1772664213983 form-group-24 "> 1879<label for="text-1772664213983" class="formbuilder-text-label">Where did you hear about our groups? 1880</label> 1881<input type="text" placeholder="" class="form-control" name="text-1772664213983" id="text-1772664213983" > 1882</div> 1883<div class="formbuilder-checkbox-group form-group field-checkboxgroup1772664233215 form-group-25 "> 1884<label for="checkboxgroup1772664233215" class="formbuilder-checkboxgrouplabel">Consent<span class="formbuilder-required">*</span></label> 1885<div class="checkbox-group"> 1886<div class="formbuilder-checkbox"> 1887<input name="checkboxgroup1772664233215" access="false" id="checkboxgroup1772664233215-1" value="yes-consent" type="checkbox" required="required" aria-required="true"><label for="checkboxgroup1772664233215-1">I consent to allow Colorado VNA to collect the information on this form</label> 1888</div> 1889</div> 1890</div>
1891<script> 1892$(document).on('submit','#tForm_8407', function(event) { 1893var response = grecaptcha.getResponse(); 1894if (!response) { 1895event.preventDefault(); //prevent form submit 1896$(this).attr('data-submit-please', 'true'); 1897grecaptcha.execute(); 1898} else { 1899var $theField = $(this).find('input[name="g-recaptcha-response"]'); 1900$theField.val(response); 1901$(this).append($theField); 1902} 1903}); 1904function recaptcha_submit(token) { 1905var $form = $('form[data-submit-please="true"]'); 1906$form.find('input[name="g-recaptcha-response"]').val(token) 1907$form.submit(); 1908} 1909</script>
1909 1910<div class="w-100 d-block" id="submitButHolder_8407"> 1911<input type="hidden" name="g-recaptcha-response" value=""> 1912<button type="submit" name="submitForm" id="submitForm_8407" class="btn btn-primary">Submit</button> 1913</div> 1914</form> 1915<hr> 1916<p class="small">*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.</p> 1917</div> 1918</div> 1919</div> 1920</div> 1921<!--Footer--> 1922<footer class="omsFooter "> 1923<style type="text/css"> 1924#gt_float_wrapper { 1925left: 5px !important; 1926bottom: 20px !important; 1927} 1928.omsFooter .list-unstyled a { 1929line-height: 1.2; 1930padding: 6px 0; 1931display: block; 1932} 1933.contacts a { 1934line-height: 1.2; 1935padding: 4px 0; 1936display: inline-block; 1937} 1938.text-primary.fab:hover, 1939.omsFooter a:not(.btn):hover { 1940color: var(--success) !important; 1941} 1942.copyrightWrapper.bg-black, 1943.copyrightWrapper a { 1944color: var(--primary) !important; 1945background: #ddd !important; 1946} 1947@media(min-width: 768px) { 1948.social-wrap { 1949order: 2; 1950} 1951.links { 1952order: 1; 1953} 1954.contacts { 1955order: 3; 1956} 1957} 1958.foot-logo img { 1959mix-blend-mode: darken; 1960} 1961.gradient-overlay { 1962position: absolute; 1963inset: 0; 1964/* top:0; right:0; bottom:0; left:0 */ 1965pointer-events: none; 1966/* lets clicks pass through */ 1967background: linear-gradient(to bottom, rgba(0, 0, 0, 0.05) 0%, rgba(0, 0, 0, 0) 100%); 1968}</style><section class="snipOuter py-4 omsFooter bg-light position-relative" id="oms_0234988" style=""><div class="gradient-overlay" data-original-title="" title=""><br></div><div class="container snip position-relative" data-original-title="" title=""><div class="row" data-original-title="" title=""><div class="col-12 col-md-4 text-center text-md-center count my-3 social-wrap" data-original-title="" title=""><div class="mb-3 mx-auto foot-logo" data-original-title="" style="width: 200px; max-width: 100%;" title=""><img alt='Colorado Visiting Nurse Association logo' class='img-fluid' src='/userfiles/2706/images/cvna_2024_logo.png'></div><p><!--{cke_protected}{C}%3C!%2D%2D%3Ca%20class%3D%22d-inline-block%20mx-2%20my-1%22%20data-original-title%3D%22%22%20data-cke-saved-href%3D%22%2FContact-Us-Now%22%20href%3D%22%2FContact-Us-Now%22%20title%3D%22%22%3EContact%20Us%3C%2Fa%3E%20%3Ca%20class%3D%22d-inline-block%20mx-2%20my-1%22%20data-original-title%3D%22%22%20data-cke-saved-href%3D%22%2FPrivacy-Practices%22%20href%3D%22%2FPrivacy-Practices%22%20title%3D%22%22%3EPrivacy%20Practices%3C%2Fa%3E%20%3Cspan%20class%3D%22d-inline-block%20mx-2%20my-1%22%20data-original-title%3D%22%22%20title%3D%22%22%3EEIN%3A%2084-1043351%3C%2Fspan%3E%2D%2D%3E--><a data-cke-saved-href="/userfiles/2706/docs/2025-tax-information.pdf" href="/userfiles/2706/docs/2025-tax-information.pdf" data-original-title="" title="">Tax Information</a></p><p><a data-cke-saved-href="/userfiles/2706/docs/notice-of-non-discrimination-2-.pdf" href="/userfiles/2706/docs/notice-of-non-discrimination-2-.pdf">Notice of Non-Discrimination</a></p><h6 class="mt-3"><span data-original-title="" style="color:var(--dark);" title=""><span data-original-title="" title=""><strong>Connect with Us</strong></span></span></h6><div class="socials mb-2" data-original-title="" title=""><a class="social-facebook" data-original-title="" data-cke-saved-href="https://www.facebook.com/ColoradoVNA" href="https://www.facebook.com/ColoradoVNA" target="_blank" title=""><i class="text-primary fab fa-facebook-square fa-fw fa-2x"></i></a> <a class="social-instagram" data-original-title="" data-cke-saved-href="" href="" target="_blank" title=""><i class="text-primary fab fa-instagram fa-fw fa-2x"></i></a> <a class="social-yelp" data-original-title="" data-cke-saved-href="" href="" target="_blank" title=""><i class="text-primary fab fa-yelp fa-fw fa-2x"></i></a> <a class="social-tripadvisor" data-original-title="" data-cke-saved-href="" href="" target="_blank" title=""><i class="text-primary fab fa-tripadvisor fa-fw fa-2x"></i> </a> <a class="social-twitter" data-original-title="" data-cke-saved-href="" href="" target="_blank" title=""><i class="text-primary fab fa-twitter fa-fw fa-2x"></i> </a> <a class="social-linkedin" data-original-title="" data-cke-saved-href="https://www.linkedin.com/company/visiting-nurse-association-of-colorado" href="https://www.linkedin.com/company/visiting-nurse-association-of-colorado" target="_blank" title=""><i class="text-primary fab fa-linkedin fa-fw fa-2x"></i> </a> <a class="social-pinterest" data-original-title="" data-cke-saved-href="" href="" target="_blank" title=""><i class="text-primary fab fa-pinterest fa-fw fa-2x"></i></a> <a class="social-youtube" data-original-title="" data-cke-saved-href="" href="" target="_blank" title=""><i class="text-primary fab fa-youtube-square fa-fw fa-2x"></i></a> <a class="social-tiktok" data-original-title="" data-cke-saved-href="[[[LOC_TIKTOKTURL]]]" href="[[[LOC_TIKTOKTURL]]]" target="_blank" title=""><i class="text-primary fab fa-tiktok fa-fw fa-2x"></i> </a></div></div><div class="col-12 col-md-4 text-center text-md-left count links my-3" data-original-title="" title=""><h5><span data-original-title="" style="color:var(--dark);" title=""><span data-original-title="" title=""><strong>Our Location</strong></span></span></h5><span class="d-block" data-original-title="" title="">6750 W 52nd Ave, Unit F</span> <span class="d-block" data-original-title="" title="">Arvada, CO 80002-3928</span> <!--{cke_protected}{C}%3C!%2D%2D%3Cspan%20class%3D%22d-block%20mt-2%22%20data-original-title%3D%22%22%20title%3D%22%22%3E%3Cstrong%3ECAPABLE%3C%2Fstrong%3E%3C%2Fspan%3E%0A%3Ca%0Aclass%3D%22d-block%22%20data-original-title%3D%22%22%20href%3D%22tel%3A303-698-6302%22%20title%3D%22%22%3E303-698-6302%3C%2Fa%3E%20%3Ca%20class%3D%22d-block%22%20data-original-title%3D%22%22%20href%3D%22mailto%3ACAPABLE%40vnacolorado.org%22%20title%3D%22%22%3ECAPABLE%40vnacolorado.org%3C%2Fa%3E%2D%2D%3E--></div><div class="col-12 col-md-4 text-center text-md-right contacts count my-3" data-original-title="" title=""><h5><span data-original-title="" style="color:var(--dark);" title=""><span data-original-title="" title=""><strong>Contact Us</strong></span></span></h5><a class="d-block" data-original-title="" data-cke-saved-href="mailto:[email protected]" href="mailto:[email protected]" title="">
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