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https://vnacolorado.org/Community-Partnerships-Companies-Foundations

html vnacolorado.org collected 2026-10-01 00:39:47 UTC 102,528 bytes, 2,079 lines download raw bytes

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">
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9<link rel="preconnect" href="https://ajax.googleapis.com" crossorigin>
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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 -->
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31<!-- Google Fonts CSS -->
32<link href="//fonts.googleapis.com/css?family=Open+Sans:400,700&display=swap" rel="stylesheet" type="text/css">
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40<script>window.omsBsPlugins={tooltip:jQuery.fn.tooltip,button:jQuery.fn.button};</script>
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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;
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56.codey {
57font-family: courier, monospace;
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62@media(min-width: 576px) {
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170white-space: normal;
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174opacity: .85;
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177color: var(--success) !important;
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180max-width: 100% !important;
181height: auto !important;
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183.rightfloat {
184float: right;
185margin: 0 0 .5rem 1rem;
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188@media (max-width: 767px) {
189.rightfloat {
190float: none;
191margin: 0 0 1rem 0;
192width: 100%;
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196color: white !important;
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201.carousel-control-next-icon,
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203background-color: rgba(0, 0, 0, 0.9);
204padding: 1rem;
205background-size: 20px;
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207@media(min-width: 1600px) {
208.container {
209max-width: 1300px;
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241padding: 1.5rem;
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282background-repeat: no-repeat;
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284/* PAGE SPECIFIC */
285/* FOOTER */
286</style>
287<script> (function(){ var s = document.createElement('script'); var h = document.querySelector('head') || document.body; s.src = 'https://acsbapp.com/apps/app/dist/js/app.js';
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289<!-- Google tag (gtag.js) -->
vendor: 64 bytes, lines 289-290
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290<script async src="https://www.googletagmanager.com/gtag/js?id=
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291<script>
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297<!-- /site header code -->
298<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/jstz.min.js"></script>
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			// ── Login submit (button + Enter key) ──────────────────────────────
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			// ── SMS ──────────────────────────────────────────────────────────────
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			// ── Forgot password ──────────────────────────────────────────────────
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">&#x2715;</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<!-- ── Login Screen ───────────────────────────────────────── -->
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<!-- ── Forgot Password Screen ────────────────────────────── -->
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<!-- ── Shared alert area ─────────────────────────────────── -->
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>&nbsp;&nbsp;<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 – 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="">&nbsp;</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&nbsp;provides high-quality health care for seniors and aging patients across the Denver metro area and surrounding areas.&nbsp;</h6>
1055<p>&nbsp;</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>“Community 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&nbsp;is so grateful to our donors and the foundation community for their understanding and support of this very special population.”</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 VNA’s 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>Brother’s 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) {
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1096column-count: 2;
1097column-gap: 1.5rem;
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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="">
1111×</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="">
1678×</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>
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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>
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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="">
1968[email protected]</a> <a class="d-block" data-original-title="" data-cke-saved-href="mailto:[email protected]" href="mailto:[email protected]" title="">[email protected]</a> <a class="d-block" data-original-title="" data-cke-saved-href="mailto:[email protected]" href="mailto:[email protected]" title="">[email protected]</a> <a class="d-block" data-original-title="" data-cke-saved-href="mailto:[email protected]" href="mailto:[email protected]" title="">[email protected]</a> <a class="d-block" data-original-title="" data-cke-saved-href="tel:303-698-2121" href="tel:303-698-2121" title="">303-698-2121</a></div></div></div></section><img class="w-100" data-cke-saved-src="/userfiles/2706/images/title-bar-banner3x.png" src="/userfiles/2706/images/title-bar-banner3x.png">
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