{"id":2172,"date":"2020-09-03T15:30:58","date_gmt":"2020-09-03T15:30:58","guid":{"rendered":"https:\/\/youhavetherightco.org\/request-for-support-service-listing\/"},"modified":"2020-09-03T16:25:51","modified_gmt":"2020-09-03T16:25:51","slug":"request-for-support-service-listing","status":"publish","type":"page","link":"https:\/\/youhavetherightco.org\/es\/request-for-support-service-listing\/","title":{"rendered":"Request for Support Service Listing"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<h1>Request for Support Service Listing<\/h1>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column]<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/es\/wp-json\/wp\/v2\/pages\/2172' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_3_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Organization Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_3_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'>Please provide a 75-word description of your organization.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_22'>This description will display with your listing <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_3_22' class='textarea medium'  aria-describedby=\"gfield_description_3_22\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_2\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_2_1_container' >\n                                        <label for='input_3_2_1' id='input_3_2_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                        <input type='text' name='input_2.1' id='input_3_2_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_2_2_container' >\n                                        <label for='input_3_2_2' id='input_3_2_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                        <input type='text' name='input_2.2' id='input_3_2_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_2_3_container' >\n                                    <label for='input_3_2_3' id='input_3_2_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                    <input type='text' name='input_2.3' id='input_3_2_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_2_4_container' >\n                                        <label for='input_3_2_4' id='input_3_2_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                        <input type='text' name='input_2.4' id='input_3_2_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_2_5_container' >\n                                    <label for='input_3_2_5' id='input_3_2_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                    <input type='text' name='input_2.5' id='input_3_2_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_3_2_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'>Judicial District<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_3_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>County or Counties<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_5\" class=\"gfield gfield--type-website gfield--input-type-website field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'>Website URL<\/label><div class='gfield_description' id='gfield_description_3_5'>Please include https:\/\/ or http:\/\/<\/div><div class='ginput_container ginput_container_website'>\n                    <input name='input_5' id='input_3_5' type='url' value='' class='medium'  aria-describedby=\"gfield_description_3_5\"  placeholder='https:\/\/'  aria-invalid=\"false\" \/>\n                <\/div><\/div><fieldset id=\"field_3_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Program Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_15'>Select one that best fits your organization<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_15'>\n\t\t\t<div class='gchoice gchoice_3_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Campus'  id='choice_3_15_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_15\"   \/>\n\t\t\t\t\t<label for='choice_3_15_0' id='label_3_15_0' class='gform-field-label gform-field-label--type-inline'>Campus<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Community-based'  id='choice_3_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>Community-based<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Culturally specific'  id='choice_3_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_2' id='label_3_15_2' class='gform-field-label gform-field-label--type-inline'>Culturally specific<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_15_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Child Advocacy Center'  id='choice_3_15_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_3' id='label_3_15_3' class='gform-field-label gform-field-label--type-inline'>Child Advocacy Center<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this a confidential resource?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_23'>\n\t\t\t<div class='gchoice gchoice_3_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_3_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_0' id='label_3_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_3_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a dedicated staff or programming specific to serving the following populations?<\/legend><div class='gfield_description' id='gfield_description_3_13'>Select all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_13'><div class='gchoice gchoice_3_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='LGBTQIA Survivors'  id='choice_3_13_1'   aria-describedby=\"gfield_description_3_13\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>LGBTQIA Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Latinx Survivors'  id='choice_3_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_2' id='label_3_13_2' class='gform-field-label gform-field-label--type-inline'>Latinx Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Survivors with disabilities'  id='choice_3_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_3' id='label_3_13_3' class='gform-field-label gform-field-label--type-inline'>Survivors with disabilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Immigrant\/Refugee Survivors'  id='choice_3_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_4' id='label_3_13_4' class='gform-field-label gform-field-label--type-inline'>Immigrant\/Refugee Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Asian Pacific Islander Survivors'  id='choice_3_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_5' id='label_3_13_5' class='gform-field-label gform-field-label--type-inline'>Asian Pacific Islander Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Native American\/Indigenous Survivors'  id='choice_3_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_6' id='label_3_13_6' class='gform-field-label gform-field-label--type-inline'>Native American\/Indigenous Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Deaf &amp; hard of hearing Survivors'  id='choice_3_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_7' id='label_3_13_7' class='gform-field-label gform-field-label--type-inline'>Deaf &amp; hard of hearing Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Undocumented Survivors'  id='choice_3_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_8' id='label_3_13_8' class='gform-field-label gform-field-label--type-inline'>Undocumented Survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='Survivors with Intellectual and developmental disabilities'  id='choice_3_13_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_9' id='label_3_13_9' class='gform-field-label gform-field-label--type-inline'>Survivors with Intellectual and developmental disabilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_13_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.11' type='checkbox'  value='N\/A'  id='choice_3_13_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_13_11' id='label_3_13_11' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Services Offered<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_14'>Select all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_14'><div class='gchoice gchoice_3_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Support groups'  id='choice_3_14_1'   aria-describedby=\"gfield_description_3_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_1' id='label_3_14_1' class='gform-field-label gform-field-label--type-inline'>Support groups<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Individual Counseling'  id='choice_3_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_2' id='label_3_14_2' class='gform-field-label gform-field-label--type-inline'>Individual Counseling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Friends and Loved Ones support groups'  id='choice_3_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_3' id='label_3_14_3' class='gform-field-label gform-field-label--type-inline'>Friends and Loved Ones support groups<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Legal Advocacy'  id='choice_3_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_4' id='label_3_14_4' class='gform-field-label gform-field-label--type-inline'>Legal Advocacy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Case management (ongoing support)'  id='choice_3_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_5' id='label_3_14_5' class='gform-field-label gform-field-label--type-inline'>Case management (ongoing support)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Protection order assistance'  id='choice_3_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_6' id='label_3_14_6' class='gform-field-label gform-field-label--type-inline'>Protection order assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='Transportation assistance'  id='choice_3_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_7' id='label_3_14_7' class='gform-field-label gform-field-label--type-inline'>Transportation assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='Food bank'  id='choice_3_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_8' id='label_3_14_8' class='gform-field-label gform-field-label--type-inline'>Food bank<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='Hotel\/housing vouchers'  id='choice_3_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_9' id='label_3_14_9' class='gform-field-label gform-field-label--type-inline'>Hotel\/housing vouchers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='Emergency Shelter'  id='choice_3_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_11' id='label_3_14_11' class='gform-field-label gform-field-label--type-inline'>Emergency Shelter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.12' type='checkbox'  value='Emergency financial assistance'  id='choice_3_14_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_12' id='label_3_14_12' class='gform-field-label gform-field-label--type-inline'>Emergency financial assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.13' type='checkbox'  value='24\/7 crisis line'  id='choice_3_14_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_13' id='label_3_14_13' class='gform-field-label gform-field-label--type-inline'>24\/7 crisis line<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.14' type='checkbox'  value='24\/7 in-person response at hospital'  id='choice_3_14_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_14' id='label_3_14_14' class='gform-field-label gform-field-label--type-inline'>24\/7 in-person response at hospital<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.15' type='checkbox'  value='24\/7 in-person response at police agency'  id='choice_3_14_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_15' id='label_3_14_15' class='gform-field-label gform-field-label--type-inline'>24\/7 in-person response at police agency<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_14_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.16' type='checkbox'  value='Language Line'  id='choice_3_14_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_14_16' id='label_3_14_16' class='gform-field-label gform-field-label--type-inline'>Language Line<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>Medical Care Hours<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_3_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_24'>24\/7 Support Line Phone Number(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_3_24' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >For counseling services, please indicate if your services are:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_16'>(select all that apply)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_16'><div class='gchoice gchoice_3_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Free'  id='choice_3_16_1'   aria-describedby=\"gfield_description_3_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>Free<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Sliding Scale'  id='choice_3_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_2' id='label_3_16_2' class='gform-field-label gform-field-label--type-inline'>Sliding Scale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Accepts Crime Victim Compensation'  id='choice_3_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_3' id='label_3_16_3' class='gform-field-label gform-field-label--type-inline'>Accepts Crime Victim Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Accepts Health Insurance'  id='choice_3_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_16_4' id='label_3_16_4' class='gform-field-label gform-field-label--type-inline'>Accepts Health Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Languages you have bilingual\/multilingual staff available to provide services in<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_9'><div class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='ASL'  id='choice_3_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>ASL<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Amharic'  id='choice_3_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_2' id='label_3_9_2' class='gform-field-label gform-field-label--type-inline'>Amharic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Arabic'  id='choice_3_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_3' id='label_3_9_3' class='gform-field-label gform-field-label--type-inline'>Arabic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Burmese'  id='choice_3_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_4' id='label_3_9_4' class='gform-field-label gform-field-label--type-inline'>Burmese<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Chinese, Mandarin'  id='choice_3_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_5' id='label_3_9_5' class='gform-field-label gform-field-label--type-inline'>Chinese, Mandarin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Chinese, Yue'  id='choice_3_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_6' id='label_3_9_6' class='gform-field-label gform-field-label--type-inline'>Chinese, Yue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='English'  id='choice_3_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_7' id='label_3_9_7' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='French'  id='choice_3_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_8' id='label_3_9_8' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='German'  id='choice_3_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_9' id='label_3_9_9' class='gform-field-label gform-field-label--type-inline'>German<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='Hindi'  id='choice_3_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_11' id='label_3_9_11' class='gform-field-label gform-field-label--type-inline'>Hindi<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='Hmong'  id='choice_3_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_12' id='label_3_9_12' class='gform-field-label gform-field-label--type-inline'>Hmong<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.13' type='checkbox'  value='Japanese'  id='choice_3_9_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_13' id='label_3_9_13' class='gform-field-label gform-field-label--type-inline'>Japanese<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.14' type='checkbox'  value='Karen, Pa\u2019o'  id='choice_3_9_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_14' id='label_3_9_14' class='gform-field-label gform-field-label--type-inline'>Karen, Pa\u2019o<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.15' type='checkbox'  value='Korean'  id='choice_3_9_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_15' id='label_3_9_15' class='gform-field-label gform-field-label--type-inline'>Korean<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.16' type='checkbox'  value='Nepali'  id='choice_3_9_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_16' id='label_3_9_16' class='gform-field-label gform-field-label--type-inline'>Nepali<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.17' type='checkbox'  value='Russian'  id='choice_3_9_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_17' id='label_3_9_17' class='gform-field-label gform-field-label--type-inline'>Russian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.18' type='checkbox'  value='Somali'  id='choice_3_9_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_18' id='label_3_9_18' class='gform-field-label gform-field-label--type-inline'>Somali<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.19' type='checkbox'  value='Spanish'  id='choice_3_9_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_19' id='label_3_9_19' class='gform-field-label gform-field-label--type-inline'>Spanish<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.21' type='checkbox'  value='Swahili'  id='choice_3_9_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_21' id='label_3_9_21' class='gform-field-label gform-field-label--type-inline'>Swahili<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.22' type='checkbox'  value='Tagalog'  id='choice_3_9_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_22' id='label_3_9_22' class='gform-field-label gform-field-label--type-inline'>Tagalog<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.23' type='checkbox'  value='Tigrigna'  id='choice_3_9_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_23' id='label_3_9_23' class='gform-field-label gform-field-label--type-inline'>Tigrigna<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.24' type='checkbox'  value='Vietnamese'  id='choice_3_9_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_24' id='label_3_9_24' class='gform-field-label gform-field-label--type-inline'>Vietnamese<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_9_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.25' type='checkbox'  value='Other'  id='choice_3_9_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_25' id='label_3_9_25' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_19\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_19'>This information will not display publicly - this is for follow-up if we have questions regarding your listing<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_19'>\n                            \n                            <span id='input_3_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_19_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_19.3' id='input_3_19_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_3_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_19_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_19.6' id='input_3_19_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_20\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_20'>This information will not display publicly <\/div><div class='ginput_container ginput_container_email'>\n                            <input 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