{"id":865,"date":"2019-09-08T23:54:04","date_gmt":"2019-09-08T23:54:04","guid":{"rendered":"http:\/\/elainespch.com\/?page_id=865"},"modified":"2026-01-13T00:13:42","modified_gmt":"2026-01-13T00:13:42","slug":"companion-form","status":"publish","type":"page","link":"https:\/\/elainespch.com\/index.php\/companion-form\/","title":{"rendered":"Companion Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"865\" class=\"elementor elementor-865\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ab19781 elementor-section-boxed elementor-section-height-default elementor-section-height-default tm-col-stretched-none tm-bg-color-over-image\" data-id=\"ab19781\" data-element_type=\"section\" data-e-type=\"section\">\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-top-column elementor-element elementor-element-52c084f tm-bg-color-over-image\" data-id=\"52c084f\" data-element_type=\"column\" data-e-type=\"column\">\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-f387df3 elementor-widget elementor-widget-text-editor\" data-id=\"f387df3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-872\"><form id=\"wpforms-form-872\" class=\"wpforms-validate wpforms-form\" data-formid=\"872\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/865\" data-token=\"8d5be5cf1706a41d9495f448d944ec93\" data-token-time=\"1792921284\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> &#8211; <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 2<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:50%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-872-field_22-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"22\"><\/div><div id=\"wpforms-872-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Caregiver Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-872-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-872-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-872-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-872-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-872-field_3-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Date in \/ Time-in <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-872-field_3\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][3][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-872-field_3\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-872-field_3-time\" class=\"wpforms-field-date-time-time wpforms-timepicker wpforms-field-required\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][3][time]\" required><label for=\"wpforms-872-field_3-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/div><div id=\"wpforms-872-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"12\"><label class=\"wpforms-field-label\">Date out \/ Time- out <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-872-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-872-field_12\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-872-field_12-time\" class=\"wpforms-field-date-time-time wpforms-timepicker wpforms-field-required\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][12][time]\" required><label for=\"wpforms-872-field_12-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/div><div id=\"wpforms-872-field_5-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"5\"><label class=\"wpforms-field-label\">Client&#039;s Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-872-field_5\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][5][first]\" required><label for=\"wpforms-872-field_5\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-872-field_5-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][5][last]\" required><label for=\"wpforms-872-field_5-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-872-field_21-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"21\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"872\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 last \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-872-field_20-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-872-field_20\">Total Hours worked <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-872-field_20\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][20]\" step=\"any\" required><\/div><div id=\"wpforms-872-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Daily Tasks<\/label><ul id=\"wpforms-872-field_17\" data-choice-limit=\"8\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"BA (Bathing\/Sponging)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_4\">BA (Bathing\/Sponging)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"BR (Dressing)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_5\">BR (Dressing)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"MD (Medication Supervison)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_6\">MD (Medication Supervison)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"EA (Eating\/Meal\/Feeding)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_7\">EA (Eating\/Meal\/Feeding)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"AM (Ambulation Assistance)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_8\">AM (Ambulation Assistance)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_9\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"CS (Cognitve Supervision)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_9\">CS (Cognitve Supervision)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-872-field_17_10\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"LS (Laundry)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-872-field_17_10\">LS (Laundry)<\/label><\/li><\/ul><\/div><div id=\"wpforms-872-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-872-field_2\">Notes <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-872-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/textarea><\/div><div id=\"wpforms-872-field_9-container\" class=\"wpforms-field wpforms-field-captcha\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-872-field_9\">Elaine&#039;s Captcha <span class=\"wpforms-required-label\">*<\/span><\/label><p id=\"wpforms-872-field_9-question\" class=\"wpforms-captcha-question\">What is 71+4?<\/p>\n\t\t<input type=\"text\" id=\"wpforms-872-field_9\" class=\"wpforms-field-medium wpforms-field-required a\" data-rule-wpf-captcha=\"qa\" data-is-wrapped-field=\"1\" data-a=\"75\" name=\"wpforms[fields][9][a]\" aria-describedby=\"wpforms-872-field_9-question\" required>\n\t\t<input type=\"hidden\" name=\"wpforms[fields][9][q]\" value=\"4\">\n\n\t\t<\/div><div id=\"wpforms-872-field_23-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"23\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-872-field-hp\" class=\"wpforms-field-label\">Name<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-872-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"872\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/elainespch.com\/index.php\/wp-json\/wp\/v2\/pages\/865\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-872\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container 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