{"id":7,"date":"2013-07-23T22:56:15","date_gmt":"2013-07-23T22:56:15","guid":{"rendered":"http:\/\/kokuacare.com\/forms\/?page_id=7"},"modified":"2013-07-23T22:56:15","modified_gmt":"2013-07-23T22:56:15","slug":"assessment-form","status":"publish","type":"page","link":"http:\/\/kokuacare.com\/forms\/assessment-form\/","title":{"rendered":"Assessment Form"},"content":{"rendered":"<div class=\"visual-form-builder-container\">\n\t\t<form id=\"assessment-1\" class=\"visual-form-builder vfb-form-1  \" method=\"post\" enctype=\"multipart\/form-data\" action=\"\">\n\t\t<input type=\"hidden\" name=\"form_id\" value=\"1\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 assessment-form    \" id=\"vfb-assessment-form-1\"><div class=\"vfb-legend\"><h3>Assessment Form<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><li class=\"vfb-item vfb-item-instructions    \" id=\"item-vfb-yes-i-am-interested-in-a-free-in-home-assessment-12\"><label for=\"vfb-yes-i-am-interested-in-a-free-in-home-assessment-12\" class=\"vfb-desc\"><h2>  Yes I am interested in a  FREE In-Home Assessment<\/h2> <\/label>Please fill out the simple form below and submit it to us to receive a free assessment of all of your home care needs. We will respond promptly with a phone call to arrange a time at your convenience.<\/li>\n<li class=\"vfb-item vfb-item-instructions    \" id=\"item-vfb-assessment-form-instructions-8\"><label for=\"vfb-assessment-form-instructions-8\" class=\"vfb-desc\">Assessment Form Instructions <\/label><h2> IMPORTANT!!  <\/h2>\r\n<bold> Please fill in all required fields designated with a red asterisk. <\/bold><\/li>\n<li class=\"vfb-item vfb-item-text    \" id=\"item-vfb-name-13\"><label for=\"vfb-name-13\" class=\"vfb-desc\">Name  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-13\" id=\"vfb-name-13\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li>\n<li class=\"vfb-item vfb-item-text    \" id=\"item-vfb-email-address-14\"><label for=\"vfb-email-address-14\" class=\"vfb-desc\">Email Address  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-14\" id=\"vfb-email-address-14\" value=\"\" class=\"vfb-text  vfb-medium  required  email \" \/><\/li>\n<li class=\"vfb-item vfb-item-text    \" id=\"item-vfb-contact-phone-include-area-code-15\"><label for=\"vfb-contact-phone-include-area-code-15\" class=\"vfb-desc\">Contact Phone (Include Area Code)  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-15\" id=\"vfb-contact-phone-include-area-code-15\" value=\"\" class=\"vfb-text  vfb-medium  required  phone \" \/><\/li>\n<li class=\"vfb-item vfb-item-radio    \" id=\"item-vfb-best-way-to-reach-you-160\"><label for=\"vfb-best-way-to-reach-you-160\" class=\"vfb-desc\">Best Way to Reach You <\/label><div><span><input type=\"radio\" name=\"vfb-160\" id=\"vfb-best-way-to-reach-you-160-0\" value=\"Email\" class=\"vfb-radio  \" \/><label for=\"vfb-best-way-to-reach-you-160-0\" class=\"vfb-choice\">Email<\/label><\/span><span><input type=\"radio\" name=\"vfb-160\" id=\"vfb-best-way-to-reach-you-160-1\" value=\"Phone\" class=\"vfb-radio  \" \/><label for=\"vfb-best-way-to-reach-you-160-1\" class=\"vfb-choice\">Phone<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li>\n<li class=\"vfb-item vfb-item-checkbox  vfb-three-column   \" id=\"item-vfb-who-are-you-looking-for-161\"><label for=\"vfb-who-are-you-looking-for-161\" class=\"vfb-desc\">Who Are You Looking For? <\/label><div><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-0\" value=\"Self\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-0\" class=\"vfb-choice\">Self<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-1\" value=\"Parent\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-1\" class=\"vfb-choice\">Parent<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-2\" value=\"Grandparent\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-2\" class=\"vfb-choice\">Grandparent<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-3\" value=\"Sibling\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-3\" class=\"vfb-choice\">Sibling<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-4\" value=\"Spouse\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-4\" class=\"vfb-choice\">Spouse<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-5\" value=\"Relative\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-5\" class=\"vfb-choice\">Relative<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-6\" value=\"Friend\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-6\" class=\"vfb-choice\">Friend<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-161[]\" id=\"vfb-who-are-you-looking-for-161-7\" value=\"Other\" class=\"vfb-checkbox  \" \/><label for=\"vfb-who-are-you-looking-for-161-7\" class=\"vfb-choice\">Other<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li>\n<li class=\"vfb-item vfb-item-checkbox  vfb-three-column   \" id=\"item-vfb-how-did-you-learn-about-us-163\"><label for=\"vfb-how-did-you-learn-about-us-163\" class=\"vfb-desc\">How Did You Learn About Us? <\/label><div><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-0\" value=\"Link\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-0\" class=\"vfb-choice\">Link<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-1\" value=\"Star Advertiser\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-1\" class=\"vfb-choice\">Star Advertiser<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-2\" value=\"MidWeek\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-2\" class=\"vfb-choice\">MidWeek<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-3\" value=\"Generations\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-3\" class=\"vfb-choice\">Generations<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-4\" value=\"ValPak\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-4\" class=\"vfb-choice\">ValPak<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-5\" value=\"Yellow Pages\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-5\" class=\"vfb-choice\">Yellow Pages<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-6\" value=\"Brochures\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-6\" class=\"vfb-choice\">Brochures<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-7\" value=\"Queens\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-7\" class=\"vfb-choice\">Queens<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-8\" value=\"Website\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-8\" class=\"vfb-choice\">Website<\/label><\/span><span><input type=\"checkbox\" name=\"vfb-163[]\" id=\"vfb-how-did-you-learn-about-us-163-9\" value=\"Referral\" class=\"vfb-checkbox  \" \/><label for=\"vfb-how-did-you-learn-about-us-163-9\" class=\"vfb-choice\">Referral<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li>\n<li class=\"vfb-item vfb-item-textarea    \" id=\"item-vfb-questions-of-comments-16\"><label for=\"vfb-questions-of-comments-16\" class=\"vfb-desc\">Questions of Comments <\/label><div><textarea name=\"vfb-16\" id=\"vfb-questions-of-comments-16\" class=\"vfb-textarea  vfb-medium    {maxWords:[100]} vfb-textarea-word-count\"><\/textarea><label class='vfb-word-count'>Maximum words allowed: <strong>100<\/strong>. Total words: <strong class='vfb-word-count-total'>0<\/strong><\/label><\/div><\/li>\n<\/ul><br \/><\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-2 verification  \" id=\"vfb-verification-2\"><div class=\"vfb-legend\"><h3>Verification<\/h3><\/div><ul class=\"vfb-section vfb-section-2\"><li class=\"vfb-item vfb-item-secret\"><label for=\"vfb-please-enter-any-two-digits-with-no-spaces-example-12-3\" class=\"vfb-desc\">Please enter any two digits with no spaces (Example: 12) <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"hidden\" name=\"_vfb-secret\" value=\"vfb-3\" \/><input type=\"text\" name=\"vfb-3\" id=\"vfb-please-enter-any-two-digits-with-no-spaces-example-12-3\" value=\"\" class=\"vfb-text  vfb-medium  required  {digits:true,maxlength:2,minlength:2} \" \/><li style=\"display:none;\"><label for=\"vfb-spam\">This box is for spam protection - <strong>please leave it blank<\/strong><\/label><div><input name=\"vfb-spam\" id=\"vfb-spam\" \/><\/div><\/li><li class=\"vfb-item vfb-item-submit\" id=\"vfb-submit-4\">\n\t\t\t\t\t<input type=\"submit\" name=\"visual-form-builder-submit\" id=\"sendmail\" value=\"Submit\" class=\"vfb-submit \" \/>\n\t\t\t\t\t<\/li><\/ul>\n\t\t <\/fieldset><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-7","page","type-page","status-publish","hentry","entry","override"],"_links":{"self":[{"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/pages\/7","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/comments?post=7"}],"version-history":[{"count":1,"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/pages\/7\/revisions"}],"predecessor-version":[{"id":8,"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/pages\/7\/revisions\/8"}],"wp:attachment":[{"href":"http:\/\/kokuacare.com\/forms\/wp-json\/wp\/v2\/media?parent=7"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}