{"id":1437,"date":"2025-04-25T23:30:52","date_gmt":"2025-04-26T03:30:52","guid":{"rendered":"https:\/\/sourcewise.gomohealth.care\/enroll\/"},"modified":"2025-09-24T08:04:08","modified_gmt":"2025-09-24T12:04:08","slug":"enroll","status":"publish","type":"page","link":"https:\/\/sourcewise.gomohealth.care\/es\/enroll\/","title":{"rendered":"Enroll"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1064.96px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 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gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var 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class='gform_body gform-body'><ul id='gform_fields_18' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_18_1\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_1\"><div class='ginput_container ginput_container_text'><input name='input_1' id='input_18_1' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_18_2\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_2\"><div class='ginput_container ginput_container_text'><input name='input_2' id='input_18_2' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/sourcewise.gomohealth.care\/es\/wp-json\/wp\/v2\/pages\/1437' \/><\/div><\/li><li id=\"field_18_3\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_3\"><div class='ginput_container ginput_container_text'><input name='input_3' id='input_18_3' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_18_50\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_18_50\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_18_50' >ctreligible<\/label><div class='ginput_container ginput_container_number'><input name='input_50' id='input_18_50' type='text'    value='1' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_18_56\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_18_56\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_18_56' >ctreligible2<\/label><div class='ginput_container ginput_container_number'><input name='input_56' id='input_18_56' type='text'    value='1' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_18_52\"  class=\"gfield gfield--width-full gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_18_52\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_18_52' >Zipcode_Eligibility<\/label><div class='ginput_container ginput_container_number'><input name='input_52' id='input_18_52' type='text'    value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_18_57\"  class=\"gfield gfield--width-full gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_18_57\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_18_57' >Zipcode_Eligibility_2<\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_18_57' type='text'    value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_18_4\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_4\"><p>Cuidar de un ser querido (por ejemplo, un familiar, amigo o vecino) puede ser dif\u00edcil de sobrellevar solo. Nuestro equipo est\u00e1 preparado para ayudarlo a encontrar una soluci\u00f3n de cuidado realista y apoyo para su ser querido. Complete el formulario de admisi\u00f3n a continuaci\u00f3n sobre usted y la persona que cuida. Esta informaci\u00f3n nos ayudar\u00e1 a saber c\u00f3mo podemos ayudarlo. Si necesita ayuda para completar este formulario, comun\u00edquese con nosotros al (408) 320-3200, opci\u00f3n 1.    <\/p>\n\n<p>Cuando termine de completar el formulario de admisi\u00f3n, obtendr\u00e1 acceso a los mensajes de texto de Sourcewise MyPlan con la funci\u00f3n de chat en tiempo real, recibir\u00e1 de 1 a 3 mensajes de texto a la semana con informaci\u00f3n \u00fatil y apoyo de nuestro equipo desde su tel\u00e9fono. Los mensajes de texto los recibir\u00e1 del n\u00famero 43386. Le sugerimos que guarde este n\u00famero como contacto en el tel\u00e9fono con el nombre \u201cSourcewise MyPlan\u201d. Puede revisar los t\u00e9rminos y condiciones <a href=\"https:\/\/sourcewise.gomohealth.care\/es\/\">https:\/\/sourcewise.gomohealth.care\/terms\/<\/a>   <\/p>\n\n<p>Adem\u00e1s de los mensajes de texto, tambi\u00e9n obtendr\u00e1 el acceso a la Biblioteca de Sourcewise MyPlan de recursos para cuidadores, personalizados con recursos para satisfacer necesidades especiales, y tambi\u00e9n con acceso a mensajer\u00eda con nosotros en tiempo real. Recibir\u00e1 un mensaje de bienvenida desde nuestra l\u00ednea de chat con el n\u00famero (833) 728-1403. Ser\u00eda una buena idea que guardara este n\u00famero en su tel\u00e9fono con el nombre \u201cSourcewise Chat\u201d. <\/p><\/li><li id=\"field_18_25\"  class=\"gfield gsection custom_section_style one mt_40 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_25\"><h2 class=\"gsection_title\">T\u00f3mese unos minutos para responder las siguientes preguntas sobre usted o el cuidador principal que se registra hoy. Queremos que sepa que toda la informaci\u00f3n compartida y recibida en nuestro programa es confidencial. Su informaci\u00f3n no se compartir\u00e1 ni usar\u00e1 para ning\u00fan otro fin.  <\/h2><\/li><li id=\"field_18_5\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_5\"><label class='gfield_label gfield_label_before_complex'  >Nombre del cuidador:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_18_5'>\n                            \n                            <span id='input_18_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_18_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_5_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_18_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_5_6' >Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_7\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_7\"><label class='gfield_label' for='input_18_7' >N\u00famero de tel\u00e9fono celular:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_18_7' type='text' value='' class='medium'  placeholder='(555) 555-5555' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_9\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_9\"><label class='gfield_label' for='input_18_9' >C\u00f3digo postal del cuidador (residencia):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_18_9' type='text' value='' class='medium'   placeholder='youremail@website.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_18_47\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_47\"><label class='gfield_label' for='input_18_47' >C\u00f3digo postal del cuidador (residencia)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_18_47' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_18_54\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_18_54\">Aseg\u00farese de ingresar un c\u00f3digo postal v\u00e1lido para continuar.<\/li><li id=\"field_18_55\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_55\">Parece que no eres elegible para continuar en este programa. Por favor, haga clic en \"Enviar\" para finalizar este formulario. <\/li><li id=\"field_18_13\"  class=\"gfield mt_25 custom_flex_style three gf_list_3col gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_13\"><label class='gfield_label gfield_label_before_complex'  >Origen \u00e9tnico del cuidador:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_18_13'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_18_13'><li class='gchoice gchoice_18_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Alaska Native'  id='choice_18_13_1'   aria-describedby=\"gfield_description_18_13\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_1' id='label_18_13_1'>Nativo de Alaska<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='American Indian'  id='choice_18_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_2' id='label_18_13_2'>Indoamericano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Asian'  id='choice_18_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_3' id='label_18_13_3'>Asi\u00e1tico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Asian Indian'  id='choice_18_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_4' id='label_18_13_4'>Indoasi\u00e1tico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Cambodian'  id='choice_18_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_5' id='label_18_13_5'>Camboyano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Chinese'  id='choice_18_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_6' id='label_18_13_6'>Chino<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Filipino'  id='choice_18_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_7' id='label_18_13_7'>Filipino<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Japanese'  id='choice_18_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_8' id='label_18_13_8'>Japon\u00e9s<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='Korean'  id='choice_18_13_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_9' id='label_18_13_9'>Coreano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.11' type='checkbox'  value='Laotian'  id='choice_18_13_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_11' id='label_18_13_11'>Laosiano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.12' type='checkbox'  value='Vietnamese'  id='choice_18_13_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_12' id='label_18_13_12'>Vietnamita<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.13' type='checkbox'  value='Other Asian'  id='choice_18_13_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_13' id='label_18_13_13'>Otro asi\u00e1tico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.14' type='checkbox'  value='Black or African American'  id='choice_18_13_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_14' id='label_18_13_14'>Afroamericano\/negro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.15' type='checkbox'  value='Hispanic or Latino'  id='choice_18_13_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_15' id='label_18_13_15'>Hispano\/Latino<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.16' type='checkbox'  value='Native Hawaiian\/Other Pacific Islander'  id='choice_18_13_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_16' id='label_18_13_16'>Hawaiano nativo\/Otro habitante de la Isla del Pac\u00edfico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.17' type='checkbox'  value='Guamanian'  id='choice_18_13_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_17' id='label_18_13_17'>Guamano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.18' type='checkbox'  value='Hawaiian'  id='choice_18_13_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_18' id='label_18_13_18'>Hawaiano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.19' type='checkbox'  value='Samoan'  id='choice_18_13_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_19' id='label_18_13_19'>Samoano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.21' type='checkbox'  value='Other Pacific Islander'  id='choice_18_13_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_21' id='label_18_13_21'>Otro habitante de la Isla del Pac\u00edfico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.22' type='checkbox'  value='White'  id='choice_18_13_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_22' id='label_18_13_22'>Blanco<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_13_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.23' type='checkbox'  value='Prefer not to disclose'  id='choice_18_13_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_13_23' id='label_18_13_23'>Prefiero no responder<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_44\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_44\"><label class='gfield_label'  >Preferencia de idioma:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_44'>\n\t\t\t<li class='gchoice gchoice_18_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='English'  id='choice_18_44_0'    \/>\n\t\t\t\t<label for='choice_18_44_0' id='label_18_44_0'>Ingl\u00e9s<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Spanish'  id='choice_18_44_1'    \/>\n\t\t\t\t<label for='choice_18_44_1' id='label_18_44_1'>Espa\u00f1ol<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_41\"  class=\"gfield mt_25 custom_flex_style three gf_list_3col gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_41\"><label class='gfield_label'  >Edad del cuidador:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_41'>\n\t\t\t<li class='gchoice gchoice_18_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='18-29'  id='choice_18_41_0'    \/>\n\t\t\t\t<label for='choice_18_41_0' id='label_18_41_0'>18-29<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='30-39'  id='choice_18_41_1'    \/>\n\t\t\t\t<label for='choice_18_41_1' id='label_18_41_1'>30-39<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_2'>\n\t\t\t\t<input name='input_41' type='radio' value='40-49'  id='choice_18_41_2'    \/>\n\t\t\t\t<label for='choice_18_41_2' id='label_18_41_2'>40-49<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_3'>\n\t\t\t\t<input name='input_41' type='radio' value='50-59'  id='choice_18_41_3'    \/>\n\t\t\t\t<label for='choice_18_41_3' id='label_18_41_3'>50-59<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_4'>\n\t\t\t\t<input name='input_41' type='radio' value='60-64'  id='choice_18_41_4'    \/>\n\t\t\t\t<label for='choice_18_41_4' id='label_18_41_4'>60-64<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_5'>\n\t\t\t\t<input name='input_41' type='radio' value='65-69'  id='choice_18_41_5'    \/>\n\t\t\t\t<label for='choice_18_41_5' id='label_18_41_5'>65-69<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_6'>\n\t\t\t\t<input name='input_41' type='radio' value='70-74'  id='choice_18_41_6'    \/>\n\t\t\t\t<label for='choice_18_41_6' id='label_18_41_6'>70-74<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_7'>\n\t\t\t\t<input name='input_41' type='radio' value='75-79'  id='choice_18_41_7'    \/>\n\t\t\t\t<label for='choice_18_41_7' id='label_18_41_7'>75-79<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_8'>\n\t\t\t\t<input name='input_41' type='radio' value='80-85'  id='choice_18_41_8'    \/>\n\t\t\t\t<label for='choice_18_41_8' id='label_18_41_8'>80-85<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_41_9'>\n\t\t\t\t<input name='input_41' type='radio' value='85+'  id='choice_18_41_9'    \/>\n\t\t\t\t<label for='choice_18_41_9' id='label_18_41_9'>85+<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_26\"  class=\"gfield gsection custom_section_style one mt_40 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_26\"><h2 class=\"gsection_title\">Brinde informaci\u00f3n adicional sobre la persona que cuida.<\/h2><\/li><li id=\"field_18_15\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_15\"><label class='gfield_label gfield_label_before_complex'  >Nombre de la persona que cuida:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_18_15'>\n                            \n                            <span id='input_18_15_3_container' class='name_first' >\n                                                    <input type='text' name='input_15.3' id='input_18_15_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_15_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_15_6_container' class='name_last' >\n                                                    <input type='text' name='input_15.6' id='input_18_15_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_15_6' >Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_16\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_16\"><label class='gfield_label'  >\u00bfCu\u00e1ntos a\u00f1os tiene la persona que cuida?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_16'>\n\t\t\t<li class='gchoice gchoice_18_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='60 years old or older'  id='choice_18_16_0'    \/>\n\t\t\t\t<label for='choice_18_16_0' id='label_18_16_0'>M\u00e1s de 60 a\u00f1os<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Less than 60 years old'  id='choice_18_16_1'    \/>\n\t\t\t\t<label for='choice_18_16_1' id='label_18_16_1'>Menos de 60 a\u00f1os<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_17\"  class=\"gfield mt_25 custom_flex_style three gf_list_3col gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_17\"><label class='gfield_label gfield_label_before_complex'  >\u00bfQu\u00e9 diagn\u00f3stico tiene la persona que cuida?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_18_17'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_18_17'><li class='gchoice gchoice_18_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Alzheimer\u2019s disease'  id='choice_18_17_1'   aria-describedby=\"gfield_description_18_17\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_1' id='label_18_17_1'>Enfermedad de Alzheimer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Mild cognitive impairments'  id='choice_18_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_2' id='label_18_17_2'>Deficiencias cognitivas leves<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Traumatic brain injury'  id='choice_18_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_3' id='label_18_17_3'>Lesi\u00f3n cerebral traum\u00e1tica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Vascular and mixed dementia'  id='choice_18_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_4' id='label_18_17_4'>Demencia vascular y mixta<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Parkinson\u2019s disease'  id='choice_18_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_5' id='label_18_17_5'>Enfermedad de Parkinson<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Huntington\u2019s disease'  id='choice_18_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_6' id='label_18_17_6'>Enfermedad de Huntington<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='Other'  id='choice_18_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_7' id='label_18_17_7'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='None'  id='choice_18_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_17_8' id='label_18_17_8'>Ninguno<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_45\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_45\"><label class='gfield_label' for='input_18_45' >Usted eligi\u00f3 &quot;Otro&quot;, por favor especifique:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_18_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_18_42\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_42\"><label class='gfield_label'  >\u00bfEl beneficiario del cuidado est\u00e1 en Medi-Cal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_42'>\n\t\t\t<li class='gchoice gchoice_18_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_18_42_0'    \/>\n\t\t\t\t<label for='choice_18_42_0' id='label_18_42_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_18_42_1'    \/>\n\t\t\t\t<label for='choice_18_42_1' id='label_18_42_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_48\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_48\"><label class='gfield_label'  >\u00bfSu Medi-Cal es a trav\u00e9s de Santa Clara Family Health Plan, Kaiser o Anthem?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_48'>\n\t\t\t<li class='gchoice gchoice_18_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Santa Clara Family Health Plan'  id='choice_18_48_0'    \/>\n\t\t\t\t<label for='choice_18_48_0' id='label_18_48_0'>Santa Clara Family Health Plan<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Kaiser'  id='choice_18_48_1'    \/>\n\t\t\t\t<label for='choice_18_48_1' id='label_18_48_1'>Kaiser<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Anthem'  id='choice_18_48_2'    \/>\n\t\t\t\t<label for='choice_18_48_2' id='label_18_48_2'>Anthem<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_48_3'>\n\t\t\t\t<input name='input_48' type='radio' value='Not sure'  id='choice_18_48_3'    \/>\n\t\t\t\t<label for='choice_18_48_3' id='label_18_48_3'>No estoy seguro<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_48_4'>\n\t\t\t\t<input name='input_48' type='radio' value='None of the above'  id='choice_18_48_4'    \/>\n\t\t\t\t<label for='choice_18_48_4' id='label_18_48_4'>Ninguno<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_58\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_58\"><label class='gfield_label'  >\u00bfEl beneficiario del cuidado recibe Servicios de Respaldo en el Hogar (IHSS) por Medi-Cal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_58'>\n\t\t\t<li class='gchoice gchoice_18_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_18_58_0'    \/>\n\t\t\t\t<label for='choice_18_58_0' id='label_18_58_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_18_58_1'    \/>\n\t\t\t\t<label for='choice_18_58_1' id='label_18_58_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_18\"  class=\"gfield mt_25 custom_flex_style three gf_list_3col gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_18\"><label class='gfield_label gfield_label_before_complex'  >\u00bfLa persona que cuida necesita ayuda con algo de lo siguiente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_18_18'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_18_18'><li class='gchoice gchoice_18_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Feeding'  id='choice_18_18_1'   aria-describedby=\"gfield_description_18_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_1' id='label_18_18_1'>Alimentarse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Dressing'  id='choice_18_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_2' id='label_18_18_2'>Vestirse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Bathing'  id='choice_18_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_3' id='label_18_18_3'>Ba\u00f1arse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Toileting'  id='choice_18_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_4' id='label_18_18_4'>Ir al ba\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Transferring (i.e., in and out of a chair)'  id='choice_18_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_5' id='label_18_18_5'>Trasladar (o sea, uso de una silla)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='Walking'  id='choice_18_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_6' id='label_18_18_6'>Caminar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_18_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.7' type='checkbox'  value='None'  id='choice_18_18_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_18_7' id='label_18_18_7'>Ninguno<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_19\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_19\"><label class='gfield_label'  >En los \u00faltimos 3 meses, \u00bfla falta de transporte confiable le impidi\u00f3 a la persona que cuida acudir a citas m\u00e9dicas, a reuniones, al trabajo o conseguir lo necesario para la vida diaria?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_19'>\n\t\t\t<li class='gchoice gchoice_18_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_18_19_0'    \/>\n\t\t\t\t<label for='choice_18_19_0' id='label_18_19_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_18_19_1'    \/>\n\t\t\t\t<label for='choice_18_19_1' id='label_18_19_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_20\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_20\"><label class='gfield_label'  >En los \u00faltimos tres meses, \u00bfla persona que cuida come menos de lo que deber\u00eda porque no hab\u00eda suficiente comida o dinero para comida en la casa?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_20'>\n\t\t\t<li class='gchoice gchoice_18_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_18_20_0'    \/>\n\t\t\t\t<label for='choice_18_20_0' id='label_18_20_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='No'  id='choice_18_20_1'    \/>\n\t\t\t\t<label for='choice_18_20_1' id='label_18_20_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_21\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_21\"><label class='gfield_label'  >\u00bfCu\u00e1ntas veces, en los \u00faltimos tres meses, la persona que cuida acudi\u00f3 a una sala de urgencias sin ser hospitalizado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_21'>\n\t\t\t<li class='gchoice gchoice_18_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='0'  id='choice_18_21_0'    \/>\n\t\t\t\t<label for='choice_18_21_0' id='label_18_21_0'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='1'  id='choice_18_21_1'    \/>\n\t\t\t\t<label for='choice_18_21_1' id='label_18_21_1'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='2'  id='choice_18_21_2'    \/>\n\t\t\t\t<label for='choice_18_21_2' id='label_18_21_2'>2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_21_3'>\n\t\t\t\t<input name='input_21' type='radio' value='3+'  id='choice_18_21_3'    \/>\n\t\t\t\t<label for='choice_18_21_3' id='label_18_21_3'>3+<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_22\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_22\"><label class='gfield_label'  >\u00bfCu\u00e1ntas veces la persona que cuida pas\u00f3 una noche o m\u00e1s en un hospital en los \u00faltimos tres meses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_22'>\n\t\t\t<li class='gchoice gchoice_18_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='0'  id='choice_18_22_0'    \/>\n\t\t\t\t<label for='choice_18_22_0' id='label_18_22_0'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='1'  id='choice_18_22_1'    \/>\n\t\t\t\t<label for='choice_18_22_1' id='label_18_22_1'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='2'  id='choice_18_22_2'    \/>\n\t\t\t\t<label for='choice_18_22_2' id='label_18_22_2'>2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='3+'  id='choice_18_22_3'    \/>\n\t\t\t\t<label for='choice_18_22_3' id='label_18_22_3'>3+<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_23\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_23\"><label class='gfield_label' for='input_18_23' >\u00bfCu\u00e1ntas noches pas\u00f3 el beneficiario de cuidados en el hospital?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_18_23' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>--seleccionar--<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><option value='32' >32<\/option><option value='33' >33<\/option><option value='34' >34<\/option><option value='35' >35<\/option><option value='36' >36<\/option><option value='37' >37<\/option><option value='38' >38<\/option><option value='39' >39<\/option><option value='40' >40<\/option><option value='41' >41<\/option><option value='42' >42<\/option><option value='43' >43<\/option><option value='44' >44<\/option><option value='45' >45<\/option><option value='46' >46<\/option><option value='47' >47<\/option><option value='48' >48<\/option><option value='49' >49<\/option><option value='50' >50<\/option><option value='51' >51<\/option><option value='52' >52<\/option><option value='53' >53<\/option><option value='54' >54<\/option><option value='55' >55<\/option><option value='56' >56<\/option><option value='57' >57<\/option><option value='58' >58<\/option><option value='59' >59<\/option><option value='60' >60<\/option><option value='61' >61<\/option><option value='62' >62<\/option><option value='63' >63<\/option><option value='64' >64<\/option><option value='65' >65<\/option><option value='66' >66<\/option><option value='67' >67<\/option><option value='68' >68<\/option><option value='69' >69<\/option><option value='70' >70<\/option><option value='71' >71<\/option><option value='72' >72<\/option><option value='73' >73<\/option><option value='74' >74<\/option><option value='75' >75<\/option><option value='76' >76<\/option><option value='77' >77<\/option><option value='78' >78<\/option><option value='79' >79<\/option><option value='80' >80<\/option><option value='81' >81<\/option><option value='82' >82<\/option><option value='83' >83<\/option><option value='84' >84<\/option><option value='85' >85<\/option><option value='86' >86<\/option><option value='87' >87<\/option><option value='88' >88<\/option><option value='89' >89<\/option><option value='90' >90<\/option><option value='91' >91<\/option><option value='92' >92<\/option><option value='93' >93<\/option><option value='94' >94<\/option><option value='95' >95<\/option><option value='96' >96<\/option><option value='97' >97<\/option><option value='98' >98<\/option><option value='99' >99<\/option><\/select><\/div><\/li><li id=\"field_18_27\"  class=\"gfield gsection custom_section_style one mt_40 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_27\"><h2 class=\"gsection_title\">Para ayudarlo, cu\u00e9ntenos un poco m\u00e1s sobre c\u00f3mo se siente como cuidador:<\/h2><\/li><li id=\"field_18_28\"  class=\"gfield gf_list_inline radio_btns_inline_style_one mt_25 custom_rating_style gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_28\"><label class='gfield_label'  >En una escala del 1 al 10, \u00bfc\u00f3mo calificar\u00eda su nivel de estr\u00e9s?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_18_28'><span style=\"color:#24a061;font-weight: 700\">1 = sin estr\u00e9s,<\/span> y <span style=\"color:#cd3c27;font-weight: 700\">10 = estr\u00e9s muy alto<\/span>.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_28'>\n\t\t\t<li class='gchoice gchoice_18_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='1'  id='choice_18_28_0'    \/>\n\t\t\t\t<label for='choice_18_28_0' id='label_18_28_0'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='2'  id='choice_18_28_1'    \/>\n\t\t\t\t<label for='choice_18_28_1' id='label_18_28_1'>2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_2'>\n\t\t\t\t<input name='input_28' type='radio' value='3'  id='choice_18_28_2'    \/>\n\t\t\t\t<label for='choice_18_28_2' id='label_18_28_2'>3<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_3'>\n\t\t\t\t<input name='input_28' type='radio' value='4'  id='choice_18_28_3'    \/>\n\t\t\t\t<label for='choice_18_28_3' id='label_18_28_3'>4<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_4'>\n\t\t\t\t<input name='input_28' type='radio' value='5'  id='choice_18_28_4'    \/>\n\t\t\t\t<label for='choice_18_28_4' id='label_18_28_4'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_5'>\n\t\t\t\t<input name='input_28' type='radio' value='6'  id='choice_18_28_5'    \/>\n\t\t\t\t<label for='choice_18_28_5' id='label_18_28_5'>6<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_6'>\n\t\t\t\t<input name='input_28' type='radio' value='7'  id='choice_18_28_6'    \/>\n\t\t\t\t<label for='choice_18_28_6' id='label_18_28_6'>7<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_7'>\n\t\t\t\t<input name='input_28' type='radio' value='8'  id='choice_18_28_7'    \/>\n\t\t\t\t<label for='choice_18_28_7' id='label_18_28_7'>8<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_8'>\n\t\t\t\t<input name='input_28' type='radio' value='9'  id='choice_18_28_8'    \/>\n\t\t\t\t<label for='choice_18_28_8' id='label_18_28_8'>9<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_28_9'>\n\t\t\t\t<input name='input_28' type='radio' value='10'  id='choice_18_28_9'    \/>\n\t\t\t\t<label for='choice_18_28_9' id='label_18_28_9'>10<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_43\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_43\"><label class='gfield_label'  >Como el cuidador principal, \u00bfcu\u00e1l es la fuente de su estr\u00e9s?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_43'>\n\t\t\t<li class='gchoice gchoice_18_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Caregiving responsibilities'  id='choice_18_43_0'    \/>\n\t\t\t\t<label for='choice_18_43_0' id='label_18_43_0'>Relacionado con las responsabilidades de cuidado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Something other than caregiving'  id='choice_18_43_1'    \/>\n\t\t\t\t<label for='choice_18_43_1' id='label_18_43_1'>Otra cosa aparte del cuidado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_43_2'>\n\t\t\t\t<input name='input_43' type='radio' value='Both'  id='choice_18_43_2'    \/>\n\t\t\t\t<label for='choice_18_43_2' id='label_18_43_2'>Ambos<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_37\"  class=\"gfield gsection custom_section_style one mt_40 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_37\"><h2 class=\"gsection_title\">En las \u00faltimas dos semanas, \u00bfcon qu\u00e9 frecuencia le causaron molestia los siguientes problemas?<\/h2><\/li><li id=\"field_18_38\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_38\"><label class='gfield_label'  >Poco inter\u00e9s o placer en hacer las actividades:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_38'>\n\t\t\t<li class='gchoice gchoice_18_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='0'  id='choice_18_38_0'    \/>\n\t\t\t\t<label for='choice_18_38_0' id='label_18_38_0'>Para nada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='1'  id='choice_18_38_1'    \/>\n\t\t\t\t<label for='choice_18_38_1' id='label_18_38_1'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_38_2'>\n\t\t\t\t<input name='input_38' type='radio' value='2'  id='choice_18_38_2'    \/>\n\t\t\t\t<label for='choice_18_38_2' id='label_18_38_2'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_38_3'>\n\t\t\t\t<input name='input_38' type='radio' value='3'  id='choice_18_38_3'    \/>\n\t\t\t\t<label for='choice_18_38_3' id='label_18_38_3'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_39\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_39\"><label class='gfield_label'  >Sensaci\u00f3n de decaimiento, depresi\u00f3n o desesperanza:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_39'>\n\t\t\t<li class='gchoice gchoice_18_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='0'  id='choice_18_39_0'    \/>\n\t\t\t\t<label for='choice_18_39_0' id='label_18_39_0'>Para nada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='1'  id='choice_18_39_1'    \/>\n\t\t\t\t<label for='choice_18_39_1' id='label_18_39_1'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_39_2'>\n\t\t\t\t<input name='input_39' type='radio' value='2'  id='choice_18_39_2'    \/>\n\t\t\t\t<label for='choice_18_39_2' id='label_18_39_2'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_39_3'>\n\t\t\t\t<input name='input_39' type='radio' value='3'  id='choice_18_39_3'    \/>\n\t\t\t\t<label for='choice_18_39_3' id='label_18_39_3'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_29\"  class=\"gfield gfield--width-full mt_25 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_29\"><label class='gfield_label'  >\u00bfNecesita un descanso de los cuidados o cuidado de relevo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_29'>\n\t\t\t<li class='gchoice gchoice_18_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_18_29_0'    \/>\n\t\t\t\t<label for='choice_18_29_0' id='label_18_29_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_18_29_1'    \/>\n\t\t\t\t<label for='choice_18_29_1' id='label_18_29_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_30\"  class=\"gfield gfield--width-full mt_25 field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_30\"><label class='gfield_label'  >\u00bfYa tiene ayuda paga?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_30'>\n\t\t\t<li class='gchoice gchoice_18_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes'  id='choice_18_30_0'    \/>\n\t\t\t\t<label for='choice_18_30_0' id='label_18_30_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No'  id='choice_18_30_1'    \/>\n\t\t\t\t<label for='choice_18_30_1' id='label_18_30_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_31\"  class=\"gfield gfield--width-full mt_25 field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_31\"><label class='gfield_label'  >\u00bfLa persona que lo ayuda est\u00e1 conectada con una agencia?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_31'>\n\t\t\t<li class='gchoice gchoice_18_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_18_31_0'    \/>\n\t\t\t\t<label for='choice_18_31_0' id='label_18_31_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_18_31_1'    \/>\n\t\t\t\t<label for='choice_18_31_1' id='label_18_31_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_33\"  class=\"gfield gfield--width-full mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_33\"><label class='gfield_label' for='input_18_33' >\u00bfC\u00f3mo se llama la agencia?<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_18_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_18_35\"  class=\"gfield gfield--width-full mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_35\"><label class='gfield_label' for='input_18_35' >\u00bfCu\u00e1l es el n\u00famero de tel\u00e9fono de la agencia?<\/label><div class='ginput_container ginput_container_phone'><input name='input_35' id='input_18_35' type='text' value='' class='medium'  placeholder='(555) 555-5555'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_46\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_18_46\"><label class='gfield_label'  >\u00bfNecesita ayuda con Medicare o tiene preguntas sobre la elegibilidad de Medi-Cal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_18_46'>\n\t\t\t<li class='gchoice gchoice_18_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_18_46_0'    \/>\n\t\t\t\t<label for='choice_18_46_0' id='label_18_46_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_18_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_18_46_1'    \/>\n\t\t\t\t<label for='choice_18_46_1' id='label_18_46_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_18_40\"  class=\"gfield mt_25 field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_40\"><label class='gfield_label' for='input_18_40' >\u00bfDesea hablar con nosotros sobre otras inquietudes?<\/label><div class='gfield_description' id='gfield_description_18_40'>Si es as\u00ed, por favor an\u00f3telos aqu\u00ed.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_18_40' class='textarea medium'  aria-describedby=\"gfield_description_18_40\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_18_49\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_18_49\"><label class='gfield_label gfield_label_before_complex'  >T\u00e9rminos y Condiciones<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_18_49'><p>La Ley de Protecci\u00f3n al Consumidor Telef\u00f3nico generalmente nos exige obtener el consentimiento antes de contactar a las personas a sus tel\u00e9fonos m\u00f3viles. Al inscribirse en este programa, usted da su consentimiento a GoMo Health para que lo contacte por mensaje de texto al n\u00famero que se inscribi\u00f3 desde el n\u00famero 43386. Puede recibir hasta 12 mensajes por semana. Tenga en cuenta que, seg\u00fan su plan de telefon\u00eda m\u00f3vil, podr\u00edan aplicarse tarifas de mensajes y datos seg\u00fan su proveedor. Tambi\u00e9n confirma que es el suscriptor o propietario del n\u00famero de m\u00f3vil proporcionado y que tiene la autoridad para dar su consentimiento. Para obtener ayuda, env\u00ede HELP por mensaje de texto al 43386. Puede darse de baja en cualquier momento respondiendo STOP o STOPALL al 43386. Para cancelar la suscripci\u00f3n a los correos electr\u00f3nicos, haga clic en \"Cancelar suscripci\u00f3n\" al final de cualquier correo electr\u00f3nico que reciba. Los T\u00e9rminos y Condiciones se encuentran en <a href=\"https:\/\/sourcewise.gomohealth.care\/es\/\">https:\/\/sourcewise.gomohealth.care\/<\/a>. La pol\u00edtica de privacidad de GoMo Health se puede encontrar aqu\u00ed: <a href=\"https:\/\/gomohealth.com\/privacy\/\">https:\/\/gomohealth.com\/privacy\/<\/a>.         <\/p><\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_18_49'><li class='gchoice gchoice_18_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='I have fully read and agreed to the terms and conditions of this program.'  id='choice_18_49_1'   aria-describedby=\"gfield_description_18_49\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_18_49_1' id='label_18_49_1'>He le\u00eddo y aceptado completamente los t\u00e9rminos y condiciones de este programa.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_18_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='I have completed the enrollment form, provided electronic consent to enroll, and I grant permission to GoMo Health to 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