{"id":108,"date":"2020-08-03T12:57:55","date_gmt":"2020-08-03T16:57:55","guid":{"rendered":"https:\/\/ontariocaregiver.ca\/peersupport\/?page_id=108"},"modified":"2023-04-28T15:15:41","modified_gmt":"2023-04-28T19:15:41","slug":"sign-up-for-a-peer-mentor","status":"publish","type":"page","link":"https:\/\/ontariocaregiver.ca\/peersupport\/sign-up-for-a-peer-mentor\/","title":{"rendered":"Sign up for a Peer Mentor"},"content":{"rendered":"<div id=\"form-block-block_5f2841fd25848\" class=\"form-block \">\n    <div class=\"form-intro\">\n                   <h2>Sign up for the Ontario Caregiver Organization 1:1 Peer Support Program Today.<\/h2>\n                        <div class=\"row\">\n            <div class=\"large-9 column\">\n                <p>Are you looking to connect with another experienced caregiver who can provide you with emotional support in your caregiving journey? If so, you have come to the right place!<br \/>\r\n<br \/>\r\nOnce registered, the Peer Support Lead will help you navigate the program and provide you with access to our exclusive and confidential online portal. With access to this portal, you can select a volunteer Peer Mentor who is a good fit for you.<br \/>\r\n<br \/>\r\nYour first name, phone number, and caregiving details listed on this registration form will be provided to your volunteer Peer Mentor. Please share what you think will be helpful for your volunteer Peer Mentor to know about you and your experience. <\/p>\n            <\/div>\n        <\/div>\n            <\/div>\n    <div class=\"the-form\">\n        <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/peersupport\/wp-json\/wp\/v2\/pages\/108#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_29\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Comments<\/label><div class='ginput_container'><input name='input_29' id='input_1_29' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_29'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >The 1:1 Peer Support program is not to be used as a substitute for counseling, psychotherapy, crisis support or any form of mental health care. The 1:1 Peer Support Program involves speaking over the phone with a trained Peer Mentor volunteer, who has lived experience as a caregiver. Thinking about your needs, are you comfortable accessing a program that connects you with a volunteer peer, not a mental health care professional?<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_1_26'>\n\t\t\t<li class='gchoice gchoice_1_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_1_26_0'    \/>\n\t\t\t\t<label for='choice_1_26_0' id='label_1_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_1_26_1'    \/>\n\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1:1 Peer Support requires that all participants sign a Confidentiality Pledge before speaking to a volunteer Peer Mentor to ensure privacy and confidentiality. The Confidentiality Pledge will be sent to you by e-mail after you complete this registration form, which can be signed digitally or through verbal consent over the phone. Are you comfortable to digitally sign or verbally consent to the Confidentiality Pledge?<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_1_28'>\n\t\t\t<li class='gchoice gchoice_1_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_1_28_0'    \/>\n\t\t\t\t<label for='choice_1_28_0' id='label_1_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_1_28_1'    \/>\n\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1:1 Peer Support provides phone-based emotional support for caregivers on issues related to caregiving. Participants and volunteer Peer Mentors are not to meet in person, to ensure safety and privacy. Are you comfortable accessing the 1:1 Peer Support program knowing that it is phone-based, and does not provide any in-person support?<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_1_27'>\n\t\t\t<li class='gchoice gchoice_1_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='Yes'  id='choice_1_27_0'    \/>\n\t\t\t\t<label for='choice_1_27_0' id='label_1_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_27_1'>\n\t\t\t\t<input name='input_27' type='radio' value='No'  id='choice_1_27_1'    \/>\n\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'>First 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_2' id='input_1_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>What pronouns do you use?<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_21\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_21'>For example: she\/her, he\/him, they\/them<\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Last 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_3' id='input_1_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Email<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_5' id='input_1_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_5\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_1_5'>Please use a valid e-mail that is regularly monitored and double check for spelling errors, as this will be the main method to contact you. If you do not use e-mail, please indicate. <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>First Three Digits of your Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Please provide your age<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you a caregiver? We define caregivers as people who provide physical or emotional support to family members, partners, friends or neighbours without pay.<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_1_25'>\n\t\t\t<li class='gchoice gchoice_1_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes'  id='choice_1_25_0'    \/>\n\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_1_25_1'    \/>\n\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Who are you caring for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_half nice-select-item length_range gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>How long have you been a caregiver?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_1_10' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a Length Range<\/option><option value='less-than-a-year' >Less than a year<\/option><option value='1-3-years' >1-3 years<\/option><option value='3-5-years' >3-5 years<\/option><option value='more-than-5-years' >more than 5 years<\/option><\/select><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full health_conditions field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What is the care recipient(s) health condition that requires your support, including both physical and\/or mental health support? Select all that apply.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_22'><li class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='brain-injury'  id='choice_1_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>Acquired brain injury <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='addiction'  id='choice_1_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_2' id='label_1_22_2' class='gform-field-label gform-field-label--type-inline'>Addiction<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='aging'  id='choice_1_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_3' id='label_1_22_3' class='gform-field-label gform-field-label--type-inline'>Aging\/old age\/frailty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='alzheimers-disease'  id='choice_1_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_4' id='label_1_22_4' class='gform-field-label gform-field-label--type-inline'>Alzheimer\u2019s disease or Dementia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='arthritis'  id='choice_1_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_5' id='label_1_22_5' class='gform-field-label gform-field-label--type-inline'>Arthritis (such as rheumatoid arthritis, osteoarthritis, lupus, gout)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='back-problems'  id='choice_1_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_6' id='label_1_22_6' class='gform-field-label gform-field-label--type-inline'>Back problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.7' type='checkbox'  value='cancer'  id='choice_1_22_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_7' id='label_1_22_7' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.8' type='checkbox'  value='cardiovascular-disease'  id='choice_1_22_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_8' id='label_1_22_8' class='gform-field-label gform-field-label--type-inline'>Cardiovascular disease (such as heart disease, heart attack, stroke)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.9' type='checkbox'  value='chronic-pain'  id='choice_1_22_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_9' id='label_1_22_9' class='gform-field-label gform-field-label--type-inline'>Chronic pain<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.11' type='checkbox'  value='developmental-disabilities'  id='choice_1_22_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_11' id='label_1_22_11' class='gform-field-label gform-field-label--type-inline'>Developmental disabilities<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.12' type='checkbox'  value='diabetes'  id='choice_1_22_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_12' id='label_1_22_12' class='gform-field-label gform-field-label--type-inline'>Diabetes <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.13' type='checkbox'  value='infectious-diseases'  id='choice_1_22_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_13' id='label_1_22_13' class='gform-field-label gform-field-label--type-inline'>Infectious diseases (such as HIV\/AIDS, Lyme Disease, Tuberculosis)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.14' type='checkbox'  value='mental-illness'  id='choice_1_22_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_14' id='label_1_22_14' class='gform-field-label gform-field-label--type-inline'>Mental illness (such as depression, bipolar disorder, eating disorder, mania or schizophrenia)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.15' type='checkbox'  value='neurological-diseases'  id='choice_1_22_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_15' id='label_1_22_15' class='gform-field-label gform-field-label--type-inline'>Neurological diseases (such as ALS, Parkinson\u2019s disease, multiple sclerosis, spina bifida, cerebral palsy, epilepsy or post-polio syndrome)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.16' type='checkbox'  value='injury-recovery'  id='choice_1_22_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_16' id='label_1_22_16' class='gform-field-label gform-field-label--type-inline'>Recovery from accident or injury<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.17' type='checkbox'  value='surgery-recovery'  id='choice_1_22_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_17' id='label_1_22_17' class='gform-field-label gform-field-label--type-inline'>Recovery from surgery<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.18' type='checkbox'  value='respiratory'  id='choice_1_22_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_18' id='label_1_22_18' class='gform-field-label gform-field-label--type-inline'>Respiratory conditions [such as Asthma, chronic bronchitis, cystic fibrosis, emphysema, chronic obstructive pulmonary disease (COPD)]<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.19' type='checkbox'  value='disability'  id='choice_1_22_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_19' id='label_1_22_19' class='gform-field-label gform-field-label--type-inline'>Visual, hearing, or physical disability<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.21' type='checkbox'  value='covid-19'  id='choice_1_22_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_21' id='label_1_22_21' class='gform-field-label gform-field-label--type-inline'>COVID-19<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.22' type='checkbox'  value='dont-know'  id='choice_1_22_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_22' id='label_1_22_22' class='gform-field-label gform-field-label--type-inline'>Don\u2019t know<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.23' type='checkbox'  value='prefer-not-to-answer'  id='choice_1_22_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_23' id='label_1_22_23' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_22_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.24' type='checkbox'  value='other'  id='choice_1_22_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_24' id='label_1_22_24' class='gform-field-label gform-field-label--type-inline'>Other (please specify)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Please specify health condition<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-textarea gfield--input-type-textarea textarea-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Describe your current caregiving experience (for example: the condition\/diagnosis of the person you are caring for, their needs, how you are coping, what are your current challenges)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_1_11' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea textarea-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>What do you hope to gain from the 1:1 Peer Support Program? What would you like a volunteer Peer Mentor to support you with?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_1_12' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do we have consent to contact you directly regarding your registration in this program?<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_1_18'>\n\t\t\t<li class='gchoice gchoice_1_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_1_18_0'    \/>\n\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_1_18_1'    \/>\n\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Are you submitting this form on behalf of someone else? (if so, please indicate your relationship to them)<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>How did you hear about the 1:1 Peer Support Program? 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