{"id":2403,"date":"2020-12-02T18:08:29","date_gmt":"2020-12-02T18:08:29","guid":{"rendered":"https:\/\/qualityhshc.com\/?page_id=2403"},"modified":"2020-12-10T17:44:56","modified_gmt":"2020-12-10T17:44:56","slug":"request-for-services","status":"publish","type":"page","link":"https:\/\/qualityhshc.com\/request-for-services\/","title":{"rendered":"Request for Services"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2403\" class=\"elementor elementor-2403\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-de4aaf4 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"de4aaf4\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-79ad40c\" data-id=\"79ad40c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-9b99de7 contact-sec-1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"9b99de7\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-920d56e\" data-id=\"920d56e\" data-element_type=\"column\" id=\"rfs-application\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-12d7f46 elementor-widget elementor-widget-text-editor\" data-id=\"12d7f46\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t        <div class=\"elementor-text-editor elementor-clearfix\"><p>Online application<\/p><\/div>\n        \t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5c6fea1 elementor-widget elementor-widget-heading\" data-id=\"5c6fea1\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-heading-wrapper\" ><div class=\"elementor-heading-wrapper-inner\"><h2 class=\"elementor-heading-title elementor-size-default\">Request for Homecare Services<\/h2><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-de4a8f5 elementor-wpcf7-button-primary elementor-wpcf7-button-md elementor-widget elementor-widget-opal-contactform7\" data-id=\"de4a8f5\" data-element_type=\"widget\" data-widget_type=\"opal-contactform7.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2384-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/2403#wpcf7-f2384-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2384\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2384-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<table width=\"573\" border=\"0\" align=\"center\" cellpadding=\"0\" cellspacing=\"0\" style=\"margin-top:25px;\">\n\t<tbody>\n\t\t<tr>\n\t\t\t<td width=\"8%\" height=\"25\" align=\"left\" valign=\"middle\" style=\"background-position:center;\">\n\t\t\t\t<table width=\"100%\" border=\"0\" cellpadding=\"5\" cellspacing=\"1\" bgcolor=\"#E0DFDF\">\n\t\t\t\t\t<tbody>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td width=\"24%\" height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Name\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td width=\"76%\" height=\"30\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-252\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-252\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Address\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"30\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-253\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required address\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-253\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>City\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"30\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-254\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required city\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-254\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>State\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"30\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-255\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required state\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-255\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Zip Code\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"30\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-256\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required zip\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-256\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"more\">Phone Number<\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"30\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"tel-107\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel phone\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-107\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"30\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Email\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email-577\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-577\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"75\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Comments\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td align=\"left\" valign=\"top\" style=\"padding-top:10px;\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-189\"><textarea cols=\"40\" rows=\"1\" class=\"wpcf7-form-control wpcf7-textarea comments\" aria-invalid=\"false\" name=\"textarea-189\"><\/textarea><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td align=\"right\" valign=\"middle\" bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t\t<p>Services Requested\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td align=\"left\" valign=\"top\" bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-796\"><span class=\"wpcf7-form-control wpcf7-checkbox requested-service\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Registered Nurse (RN)\" \/><span class=\"wpcf7-list-item-label\">Registered Nurse (RN)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Licensed Practical Nurse (LPN)\" \/><span class=\"wpcf7-list-item-label\">Licensed Practical Nurse (LPN)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Certified Home Health Aide\" \/><span class=\"wpcf7-list-item-label\">Certified Home Health Aide<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Companion\/Homemaker\" \/><span class=\"wpcf7-list-item-label\">Companion\/Homemaker<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Physical Therapist (PT)\" \/><span class=\"wpcf7-list-item-label\">Physical Therapist (PT)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Infusion Therapy\" \/><span class=\"wpcf7-list-item-label\">Infusion Therapy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Medication Reminders\" \/><span class=\"wpcf7-list-item-label\">Medication Reminders<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Light Housekeeping\" \/><span class=\"wpcf7-list-item-label\">Light Housekeeping<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Mail Assistance and Organization\/Bill Paying\" \/><span class=\"wpcf7-list-item-label\">Mail Assistance and Organization\/Bill Paying<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Transportation and Escort to Appointments\" \/><span class=\"wpcf7-list-item-label\">Transportation and Escort to Appointments<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Grooming\" \/><span class=\"wpcf7-list-item-label\">Grooming<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Feeding\" \/><span class=\"wpcf7-list-item-label\">Feeding<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Transport and Positioning\" \/><span class=\"wpcf7-list-item-label\">Transport and Positioning<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Meal Preparation\" \/><span class=\"wpcf7-list-item-label\">Meal Preparation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Laundry and Linen Washing\" \/><span class=\"wpcf7-list-item-label\">Laundry and Linen Washing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Conversation and Companionship\" \/><span class=\"wpcf7-list-item-label\">Conversation and Companionship<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Respite and Relief for Family\" \/><span class=\"wpcf7-list-item-label\">Respite and Relief for Family<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Bathing and Dressing\" \/><span class=\"wpcf7-list-item-label\">Bathing and Dressing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Personal and Oral Hygiene\" \/><span class=\"wpcf7-list-item-label\">Personal and Oral Hygiene<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-796[]\" value=\"Ambulation\" \/><span class=\"wpcf7-list-item-label\">Ambulation<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"35\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Times Requested\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"35\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-257\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text times\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-257\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"35\" align=\"right\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p>Dates Requested\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"35\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-258\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text dates\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-258\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"35\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"35\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><strong>Thank you for your interest.<\/strong>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t\t<p>A representative of Home Sweet Home Care will contact you.\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<tr bgcolor=\"#FFFFFF\">\n\t\t\t\t\t\t\t<td height=\"35\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t\t<td height=\"35\" align=\"left\" valign=\"middle\">\n\t\t\t\t\t\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner send-btn\" type=\"submit\" value=\"Submit\" \/>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/td>\n\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t<\/tbody>\n\t\t\t\t<\/table>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"238\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Online application Request for Homecare Services Name Address City State Zip Code Phone Number Email Comments Services Requested Registered Nurse (RN)Licensed Practical Nurse (LPN)Certified Home Health AideCompanion\/HomemakerPhysical Therapist (PT)Infusion TherapyMedication RemindersLight HousekeepingMail Assistance and Organization\/Bill PayingTransportation and Escort to AppointmentsGroomingFeedingTransport and PositioningMeal PreparationLaundry and Linen WashingConversation and CompanionshipRespite and Relief for FamilyBathing and DressingPersonal and &hellip; <\/p>\n<p class=\"link-more\"><a href=\"https:\/\/qualityhshc.com\/request-for-services\/\" class=\"more-link\">Read More <span class=\"screen-reader-text\"> &#8220;Request for Services&#8221;<\/span><\/a><\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-elementor.php","meta":{"inline_featured_image":false,"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.2 - 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