{"id":33,"date":"2020-04-21T16:31:44","date_gmt":"2020-04-21T16:31:44","guid":{"rendered":"https:\/\/lwr.esinc.org\/?page_id=33"},"modified":"2023-08-24T13:57:00","modified_gmt":"2023-08-24T13:57:00","slug":"request-information","status":"publish","type":"page","link":"https:\/\/lwr.esinc.org\/request-information\/","title":{"rendered":"Request Information"},"content":{"rendered":"\t<section class=\"section\" id=\"section_1022134513\">\n\t\t<div class=\"bg section-bg fill bg-fill  bg-loaded\" >\n\n\t\t\t\n\t\t\t\n\t\t\t\n\n\t\t<\/div>\n\n\t\t\n\n\t\t<div class=\"section-content relative\">\n\t\t\t\n<div class=\"row row-large align-center\"  id=\"row-2082093648\">\n\n\t<div id=\"col-1545437032\" class=\"col medium-7 small-12 large-7\"  >\n\t\t\t\t<div class=\"col-inner dark\" style=\"background-color:#375e97;\" >\n\t\t\t\n\t\t\t\n<div class=\"container section-title-container\" ><h2 class=\"section-title section-title-center\"><b><\/b><span class=\"section-title-main\" >I\u2019d like to live with a Family Home Provider<\/span><b><\/b><\/h2><\/div>\n<div data-uniq='65f2a9ca3f835' class='uniq-65f2a9ca3f835 formcraft-css form-live align-left'><style type='text\/css' scoped='scoped'>html .formcraft-css .powered-by {\n    display: none!important;\n}<\/style><script> window.formcraftLogic = window.formcraftLogic || {}; window.formcraftLogic[1] = [[[[\"field8\",\"equal_to\",\"Yes\"]],[[\"show_fields\",\"field5,field6\"]],\"and\"]]; <\/script><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination width-100\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-1 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: none !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title\n\t\t\t{\n\t\t\t\tbackground: #f1592a;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #f1592a;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #d44e24;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #d44e24;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #f1592a;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #f1592a;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #d44e24;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-1.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form .final-success .final-success-check {\n\t\t\t\tborder: 2px solid #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover .time-fields-cover,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover .awesomplete ul\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"radio\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"checkbox\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"radio\"]:checked,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .field-cover input[type=\"checkbox\"]:checked {\n\t\t\t\tborder-color: #d44e24;\n\t\t\t\tbackground: #f1592a;\t\t\t\t\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #d44e24;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #d44e24 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .fileupload-cover .button-file\n\t\t\t{\n\t\t\t\tborder-color: #d44e24;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #f1592a;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-1\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: none;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-auto-scroll=\"\" data-no-message-redirect=\"\" data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"1\" class=\"fc-form fc-form-1 align- fc-temp-class save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-placeholder field-border-visible frame-hidden field-alignment-left  \" style=\"width: 100%; color: #666666; font-size: 100%; background: none\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field1\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field1 options-false index-false form-element-0 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Name<\/span><\/span><span class=\"sub-label\"><span >your full name<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Name\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-face\">face<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field2 options-false index-false form-element-1 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >your phone<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Phone Number\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-call\">call<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"2\" style=\"width: 100%\" class=\" form-element form-element-field3 options-false index-false form-element-2 default-false form-element-type-email is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"email-cover field-cover  \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Email<\/span><\/span><span class=\"sub-label\"><span >a valid email<\/span><\/span><\/span><div><span class=\"error\"><\/span><input placeholder=\"Email\" data-field-id=\"field3\" type=\"text\" data-val-type=\"email\" make-read-only=\"\" data-is-required=\"false\" name=\"field3\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">email<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"3\" style=\"width: 100%\" class=\" even form-element form-element-field4 form-element-3 default-false form-element-type-dropdown is-required-true options-false index-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type- \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Do you presently have the SCL waiver?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"true\" class=\"validation-lenient\" data-field-id=\"field4\" name=\"field4\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \">Do you presently have the SCL waiver?<\/option><option value=\"Yes\" class=\" \">Yes<\/option><option value=\"No\" class=\" \">No<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field8\" data-index=\"4\" style=\"width: 100%; position: relative; z-index: 101; left: 0px; top: 0px\" class=\" form-element form-element-field8 default-false form-element-type-dropdown -handle odd form-element-4 is-required-true options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type- \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Language<\/span><\/span><span class=\"sub-label\"><span >pick one!<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"true\" class=\"validation-lenient\" data-field-id=\"field8\" name=\"field8\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \">Do you have a case manager?<\/option><option value=\"Yes\" class=\" \">Yes<\/option><option value=\"No\" class=\" \">No<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field5\" data-index=\"5\" style=\"width: 100%\" class=\" form-element form-element-field5 options-false index-false default-true form-element-type-oneLineText is-required-false -handle even form-element-5\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Case Manager Name<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Case Manager Name\" make-read-only=\"false\" data-field-id=\"field5\" name=\"field5[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field6\" data-index=\"6\" style=\"width: 100%\" class=\" form-element form-element-field6 options-false index-false default-true form-element-type-oneLineText is-required-false -handle odd form-element-6\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover  \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Case Manager Phone Number<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Case Manager Phone Number\" make-read-only=\"false\" data-field-id=\"field6\" name=\"field6[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field7\" data-index=\"7\" style=\"width: 100%\" class=\" form-element form-element-field7 options- index- default-false form-element-type-submit is-required-false -handle even form-element-7\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit Form<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><label ><input type=\"text\" class=\"required_field\" name=\"website\" autocomplete=\"maple-syrup-pot\"><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 100%; color: #666666; font-size: 100%; background: none\">\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\n\t\t<\/div>\n\t\t\t\t\n<style>\n#col-1545437032 > .col-inner {\n  padding: 40px 40px 40px 40px;\n}\n<\/style>\n\t<\/div>\n\n\t\n<\/div>\n\t\t<\/div>\n\n\t\t\n<style>\n#section_1022134513 {\n  padding-top: 40px;\n  padding-bottom: 40px;\n}\n#section_1022134513 .ux-shape-divider--top svg {\n  height: 150px;\n  --divider-top-width: 100%;\n}\n#section_1022134513 .ux-shape-divider--bottom svg {\n  height: 150px;\n  --divider-width: 100%;\n}\n<\/style>\n\t<\/section>\n\t\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-blank.php","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Request Information - Life Works<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/lwr.esinc.org\/request-information\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Request Information - Life Works\" \/>\n<meta property=\"og:url\" content=\"https:\/\/lwr.esinc.org\/request-information\/\" \/>\n<meta property=\"og:site_name\" content=\"Life Works\" \/>\n<meta property=\"article:modified_time\" content=\"2023-08-24T13:57:00+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" 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