{"id":1152,"date":"2024-10-05T02:05:18","date_gmt":"2024-10-05T02:05:18","guid":{"rendered":"http:\/\/www.premierhavenhealthcare.co.uk\/draft\/?page_id=1152"},"modified":"2024-10-08T21:37:58","modified_gmt":"2024-10-08T21:37:58","slug":"care-request-form","status":"publish","type":"page","link":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/care-request-form\/","title":{"rendered":"Care Request Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.2&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;gcid-0b01efc9-0224-4aaf-ac66-6bbcd6750db9&#8243; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_direction=&#8221;90deg&#8221; background_color_gradient_stops=&#8221;gcid-heading-color 0%|rgba(41,196,169,0) 71%&#8221; background_color_gradient_overlays_image=&#8221;on&#8221; background_image=&#8221;http:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-content\/uploads\/2023\/07\/disability_care.png&#8221; custom_padding=&#8221;0%||0%||true|false&#8221; global_colors_info=&#8221;{%22gcid-0b01efc9-0224-4aaf-ac66-6bbcd6750db9%22:%91%22background_color%22,%22background_color%22%93,%22gcid-aae2d59c-aa72-43e2-bbec-3fd3aa7584ca%22:%91%22background_color_gradient_stops%22%93,%22gcid-secondary-color%22:%91%22background_color_gradient_stops%22%93,%22gcid-heading-color%22:%91%22background_color_gradient_stops%22%93}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; make_equal=&#8221;on&#8221; _builder_version=&#8221;4.25.1&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; max_width=&#8221;1600px&#8221; custom_padding=&#8221;5%|5%|5%|5%|true|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; header_font=&#8221;|600|||||||&#8221; header_text_color=&#8221;#FFFFFF&#8221; header_font_size=&#8221;38px&#8221; header_2_text_color=&#8221;#FFFFFF&#8221; header_2_font_size=&#8221;35px&#8221; header_font_size_tablet=&#8221;4vw&#8221; header_font_size_phone=&#8221;6vw&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Request Care<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; disabled_on=&#8221;on|on|off&#8221; _builder_version=&#8221;4.27.2&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;gcid-heading-color&#8221; custom_padding=&#8221;0%||0%||true|false&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{%22gcid-heading-color%22:%91%22background_color%22%93}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; make_equal=&#8221;on&#8221; _builder_version=&#8221;4.25.1&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; max_width=&#8221;1600px&#8221; custom_padding=&#8221;0px|5%|0px|5%|true|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.25.1&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0.2%||0.2%||true|false&#8221; global_colors_info=&#8221;{}&#8221;][lwp_divi_breadcrumbs link_color=&#8221;#000000&#8243; current_text_color=&#8221;#FFFFFF&#8221; _builder_version=&#8221;4.25.1&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][\/lwp_divi_breadcrumbs][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;2px||2%||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; make_equal=&#8221;on&#8221; _builder_version=&#8221;4.27.2&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; max_width=&#8221;100%&#8221; custom_padding=&#8221;|5%||5%|false|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; background_enable_color=&#8221;off&#8221; custom_padding=&#8221;2%||2%||true|false&#8221; border_radii=&#8221;on|5px|5px|5px|5px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.2&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p>We recognise that finding the right care solution can be a complicated and emotional journey, and we are committed to assisting you throughout the entire process.<\/p>\n<p>Beginning with initial questions and leading to the creation of customised care plans, we strive to guarantee that you obtain the necessary assistance<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; make_equal=&#8221;on&#8221; _builder_version=&#8221;4.27.2&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; max_width=&#8221;1600px&#8221; custom_padding=&#8221;|5%||5%|false|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; background_enable_color=&#8221;off&#8221; custom_padding=&#8221;2%|3%|2%|3%|true|true&#8221; border_radii=&#8221;on|5px|5px|5px|5px&#8221; box_shadow_style=&#8221;preset1&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_code _builder_version=&#8221;4.27.2&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;RGBA(255,255,255,0)&#8221; global_colors_info=&#8221;{}&#8221;]<div class=\"forminator-ui forminator-custom-form forminator-custom-form-1271 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1271\" data-uid=\"6adfe8ba2f250\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1271\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1271 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1271\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6adfe8ba2f250\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1271__field--select-1_6adfe8ba2f250\" id=\"forminator-form-1271__field--select-1_6adfe8ba2f250-label\" class=\"forminator-label\">Who needs the care ? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1271__field--select-1_6adfe8ba2f250\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"- please select -\" data-search=\"false\" data-search-placeholder=\"- please select -\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1271__field--select-1_6adfe8ba2f250-label\"><option value=\"\"  >- please select -<\/option><option value=\"one0\"  data-calculation=\"0\">- please select -<\/option><option value=\"one1\"  data-calculation=\"0\">Mother<\/option><option value=\"one2\"  data-calculation=\"0\">Father<\/option><option value=\"one3\"  data-calculation=\"0\">Grandmother<\/option><option value=\"one4\"  data-calculation=\"0\">Grandfather<\/option><option value=\"one5\"  data-calculation=\"0\">Wife<\/option><option value=\"one6\"  data-calculation=\"0\">Husband<\/option><option value=\"one7\"  data-calculation=\"0\">Daughter<\/option><option value=\"one8\"  data-calculation=\"0\">Son<\/option><option value=\"one9\"  data-calculation=\"0\">Myself<\/option><option value=\"one10\"  data-calculation=\"0\">Relative<\/option><option value=\"one11\"  data-calculation=\"0\">Friend<\/option><option value=\"one12\"  data-calculation=\"0\">Patient<\/option><option value=\"one13\"  data-calculation=\"0\">Client<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1271__field--select-2_6adfe8ba2f250\" 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Care<\/option><option value=\"one19\"  data-calculation=\"0\">Live-in Care<\/option><option value=\"one20\"  data-calculation=\"0\">Daytime Care<\/option><option value=\"one21\"  data-calculation=\"0\">I am not Sure<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6adfe8ba2f250\" id=\"forminator-field-first-name-1_6adfe8ba2f250-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_6adfe8ba2f250\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6adfe8ba2f250\" id=\"forminator-field-last-name-1_6adfe8ba2f250-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_6adfe8ba2f250\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6adfe8ba2f250\" id=\"forminator-field-email-1_6adfe8ba2f250-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6adfe8ba2f250\" class=\"forminator-input forminator-email--field\" data-required=\"true\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6adfe8ba2f250\" id=\"forminator-field-phone-1_6adfe8ba2f250-label\" class=\"forminator-label\">Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6adfe8ba2f250\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"gb\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6adfe8ba2f250\" id=\"forminator-field-textarea-1_6adfe8ba2f250-label\" class=\"forminator-label\">What are your needs<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6adfe8ba2f250\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" maxlength=\"180\" ><\/textarea><span id=\"forminator-field-textarea-1_6adfe8ba2f250-description\" class=\"forminator-description\"><span data-limit=\"180\" data-type=\"characters\" data-editor=\"\">0 \/ 180<\/span><\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6adfe8ba2f250-label\"><label id=\"forminator-field-checkbox-1-1-6adfe8ba2f250-label\" for=\"forminator-field-checkbox-1-1-6adfe8ba2f250\" class=\"forminator-checkbox\" title=\"By using this form you agree with the storage and handling of your data by this website as defined in our Privacy Policy.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6adfe8ba2f250\" aria-labelledby=\"forminator-field-checkbox-1-1-6adfe8ba2f250-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">By using this form you agree with the storage and handling of your data by this website as defined in our Privacy Policy.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\" style=\"margin: 0;\"><div id=\"captcha-1\" class=\"forminator-field-captcha  forminator-col-12 \"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"bottomright\" data-sitekey=\"6LfPtMYnAAAAAPaNYjSqvRRJrpinHYhX3xwshLFB\" data-size=\"invisible\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Send Request<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"be9fdbb40a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/draft\/wp-json\/wp\/v2\/pages\/1152\" \/><input type=\"hidden\" name=\"form_id\" value=\"1271\"><input type=\"hidden\" name=\"page_id\" value=\"1152\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/care-request-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Request Care<div class=\"et_pb_module lwp_divi_breadcrumbs lwp_divi_breadcrumbs_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"lwp-breadcrumbs\"> <span class=\"before\"><\/span> <span vocab=\"https:\/\/schema.org\/\" typeof=\"BreadcrumbList\"><span property=\"itemListElement\" typeof=\"ListItem\"><a property=\"item\" typeof=\"WebPage\" href=\"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/\" class=\"home\"><span property=\"name\">Home<\/span><\/a><meta property=\"position\" content=\"1\"><\/span> <span class=\"separator et-pb-icon\">&#x39;<\/span> <\/span><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>We recognise that finding the right care solution can be a complicated and emotional journey, and we are committed to assisting you throughout the entire process. Beginning with initial questions and leading to the creation of customised care plans, we strive to guarantee that you obtain the necessary [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-1152","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/pages\/1152","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/comments?post=1152"}],"version-history":[{"count":4,"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/pages\/1152\/revisions"}],"predecessor-version":[{"id":1274,"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/pages\/1152\/revisions\/1274"}],"wp:attachment":[{"href":"https:\/\/www.premierhavenhealthcare.co.uk\/draft\/wp-json\/wp\/v2\/media?parent=1152"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}