{"id":198,"date":"2023-09-15T11:54:31","date_gmt":"2023-09-15T11:54:31","guid":{"rendered":"https:\/\/care4yourself.net\/dir\/?page_id=198"},"modified":"2023-09-19T12:03:49","modified_gmt":"2023-09-19T12:03:49","slug":"form-page","status":"publish","type":"page","link":"https:\/\/care4yourself.net\/dir\/form-page\/","title":{"rendered":"Form page"},"content":{"rendered":"\n<p>All fields are optional, but please provide as much information as you are comfortable sharing:<\/p>\n\n\n<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-d5a57803-43e7-41e7-81cd-00b94cb0d276 wpforms-render-modern\" id=\"wpforms-119\"><form id=\"wpforms-form-119\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"119\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/dir\/wp-json\/wp\/v2\/pages\/198\" data-token=\"4ee463e756a106fe75d75b0752a9f281\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-119-field_1-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-119-field_1\">How did you find this site?<\/label><select id=\"wpforms-119-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\"><option value=\"Billboard\"  selected='selected'>Billboard<\/option><option value=\"Social media\" >Social media<\/option><option value=\"Newspaper advertisement\" >Newspaper advertisement<\/option><option value=\"Radio advertisement\" >Radio 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for=\"wpforms-119-field_3_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_4-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label\">Have you or a family member struggled with opioid addiction?<\/legend><ul id=\"wpforms-119-field_4\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_4_1\" name=\"wpforms[fields][4]\" value=\"Yes\" aria-errormessage=\"wpforms-119-field_4_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_4_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_4_2\" name=\"wpforms[fields][4]\" value=\"No\" aria-errormessage=\"wpforms-119-field_4_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_4_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Have you sought treatment for substance abuse in the past?<\/legend><ul id=\"wpforms-119-field_5\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_5_1\" name=\"wpforms[fields][5]\" value=\"Yes\" aria-errormessage=\"wpforms-119-field_5_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_5_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_5_2\" name=\"wpforms[fields][5]\" value=\"No\" aria-errormessage=\"wpforms-119-field_5_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_5_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Have public resources been able to help you seek treatment or prevent substance abuse?<\/legend><ul id=\"wpforms-119-field_6\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_6_1\" name=\"wpforms[fields][6]\" value=\"Yes\" aria-errormessage=\"wpforms-119-field_6_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_6_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_6_2\" name=\"wpforms[fields][6]\" value=\"No\" aria-errormessage=\"wpforms-119-field_6_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_6_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_7-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"7\"><fieldset><legend class=\"wpforms-field-label\">Has this site been helpful to you?<\/legend><ul id=\"wpforms-119-field_7\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_7_1\" name=\"wpforms[fields][7]\" value=\"Yes\" aria-errormessage=\"wpforms-119-field_7_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_7_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_7_2\" name=\"wpforms[fields][7]\" value=\"No\" aria-errormessage=\"wpforms-119-field_7_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_7_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_11-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Name (Optional)<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-119-field_11\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][11][first]\" aria-errormessage=\"wpforms-119-field_11-error\" ><label for=\"wpforms-119-field_11\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-119-field_11-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][11][last]\" aria-errormessage=\"wpforms-119-field_11-last-error\" ><label for=\"wpforms-119-field_11-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-119-field_18-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Age<\/legend><ul id=\"wpforms-119-field_18\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_18_1\" name=\"wpforms[fields][18]\" value=\"0-18\" aria-errormessage=\"wpforms-119-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_18_1\">0-18<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_18_2\" name=\"wpforms[fields][18]\" value=\"19-35\" aria-errormessage=\"wpforms-119-field_18_2-error\"  ><label 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aria-errormessage=\"wpforms-119-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_12_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_12_2\" name=\"wpforms[fields][12]\" value=\"Female\" aria-errormessage=\"wpforms-119-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_12_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_12_3\" name=\"wpforms[fields][12]\" value=\"Nonbinary\" aria-errormessage=\"wpforms-119-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_12_3\">Nonbinary<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-119-field_14\">Gender<\/label><input type=\"text\" id=\"wpforms-119-field_14\" 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data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Race (U.S. Census categories)<\/legend><ul id=\"wpforms-119-field_20\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_20_1\" name=\"wpforms[fields][20]\" value=\"White\" aria-errormessage=\"wpforms-119-field_20_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_20_1\">White<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_20_2\" name=\"wpforms[fields][20]\" value=\"Black\" aria-errormessage=\"wpforms-119-field_20_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_20_2\">Black<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_20_3\" name=\"wpforms[fields][20]\" value=\"Native American\" aria-errormessage=\"wpforms-119-field_20_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_20_3\">Native American<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_20_4\" name=\"wpforms[fields][20]\" value=\"Asian\" aria-errormessage=\"wpforms-119-field_20_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_20_4\">Asian<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_20_5\" name=\"wpforms[fields][20]\" value=\"Pacific Islander\" aria-errormessage=\"wpforms-119-field_20_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_20_5\">Pacific Islander<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-119-field_21-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-119-field_21\">Why did you visit this site?<\/label><textarea id=\"wpforms-119-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-119-field_21-error\" ><\/textarea><\/div><div id=\"wpforms-119-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-119-field_22\">Tell us your story<\/label><textarea id=\"wpforms-119-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-119-field_22-error\" ><\/textarea><\/div><div id=\"wpforms-119-field_17-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-119-field_17\">Email<\/label><input type=\"email\" id=\"wpforms-119-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" spellcheck=\"false\" aria-errormessage=\"wpforms-119-field_17-error\" ><\/div><div id=\"wpforms-119-field_23-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">May we contact you with more information addiction resources?<\/legend><ul id=\"wpforms-119-field_23\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_23_1\" name=\"wpforms[fields][23]\" value=\"Yes\" aria-errormessage=\"wpforms-119-field_23_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_23_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-119-field_23_2\" name=\"wpforms[fields][23]\" value=\"No\" aria-errormessage=\"wpforms-119-field_23_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-119-field_23_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha\" ><div class=\"g-recaptcha\" data-sitekey=\"6Lem-jgoAAAAADyipCr_fAl5cwCHksOfZVn3uV6d\" data-size=\"invisible\"><\/div><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"119\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button 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