{"id":14102,"date":"2026-04-06T13:44:51","date_gmt":"2026-04-06T20:44:51","guid":{"rendered":"https:\/\/ucpofcentralaz.org\/?page_id=14102"},"modified":"2026-04-07T11:31:40","modified_gmt":"2026-04-07T18:31:40","slug":"hcbs-reference-form","status":"publish","type":"page","link":"https:\/\/ucpofcentralaz.org\/es\/hcbs-reference-form\/","title":{"rendered":"HCBS Reference Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\" id=\"wpb-content-root\"><div class=\"qodef-content-grid\"><div class=\"vc_row wpb_row vc_row-fluid qodef-row-over vc_custom_1588660382827 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"qodef-content-grid\"><div class=\"vc_row wpb_row vc_inner vc_row-fluid vc_custom_1588785107927 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner vc_custom_1587620256476\"><div class=\"wpb_wrapper\"><div class=\"qodef-shortcode qodef-m  qodef-section-title qodef-alignment--center qodef-title-break--disabled\">\n\t\t\t\t<h2 class=\"qodef-m-title\" >\n\t\t\t\t\tUCP HCBS Reference Form\t\t\t<\/h2>\n\t<\/div>\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<div class=\"wpb_text_column wpb_content_element \">\n<div class=\"wpb_wrapper\">\n<h4 style=\"text-align: center;\">Please complete the questions listed below. Keep in mind that direct care worker services are typically performed unsupervised in the home of a person with physical or developmental disabilities. UCP of Central Arizona will maintain strict confidentiality of your responses in accordance with the law. We appreciate your time and effort.<\/h4>\n<\/div>\n<\/div>\n\n\t\t<\/div>\n\t<\/div>\n<div class=\"vc_empty_space\"   style=\"height: 32px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_37' ><style>#gform_wrapper_37[data-form-index=\"0\"].gform-theme{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">References<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_37'  action='\/es\/wp-json\/wp\/v2\/pages\/14102' data-formid='37' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"20\" \/>\n\t\t\t\t\t\t<script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n\n\t\t\t\t\t<\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_37' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_37_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Applicant:<\/h3><\/div><fieldset id=\"field_37_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_37_1'>*Enter the name of the person who requested this form.<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_37_1'>\n                            \n                            <span id='input_37_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_37_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_37_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_1.4' id='input_37_1_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_37_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_37_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_37_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_37_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Person Completing Form:<\/h3><div class='gsection_description' id='gfield_description_37_24'>Please Note: We cannot accept references completed by family members of the applicant.<\/div><\/div><fieldset id=\"field_37_23\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_37_23'>\n                            \n                            <span id='input_37_23_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_23_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_23.3' id='input_37_23_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_37_23_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_23_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_23.4' id='input_37_23_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_37_23_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_37_23_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_23.6' id='input_37_23_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_37_21\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_37_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_37_21_1_container' >\n                                        <label for='input_37_21_1' id='input_37_21_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_21.1' id='input_37_21_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_37_21_2_container' >\n                                        <label for='input_37_21_2' id='input_37_21_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_21.2' id='input_37_21_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_37_21_3_container' >\n                                    <label for='input_37_21_3' id='input_37_21_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_21.3' id='input_37_21_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_37_21_4_container' >\n                                        <label for='input_37_21_4' id='input_37_21_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_21.4' id='input_37_21_4' value=''      aria-required='true'   autocomplete=\"address-level1\" \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_37_21_5_container' >\n                                    <label for='input_37_21_5' id='input_37_21_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_21.5' id='input_37_21_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_37_21_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_37_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Email Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_37_2_container'>\n                                <span id='input_37_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_37_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_2' id='input_37_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_37_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_37_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_37_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_37_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_10'><span class='gform-field-label__text'>Your Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_37_10' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_37_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Indicate the length of time you have known the applicant: (required\u2014select one):<\/h3><\/div><fieldset id=\"field_37_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Position You&#039;re Applying For<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_3'>\n\t\t\t<div class='gchoice gchoice_37_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Less than 1 year'  id='choice_37_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_0' id='label_37_3_0' class='gform-field-label gform-field-label--type-inline'>Less than 1 year<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Between 1 year and 3 years'  id='choice_37_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_1' id='label_37_3_1' class='gform-field-label gform-field-label--type-inline'>Between 1 year and 3 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Between 4 years and 7 years'  id='choice_37_3_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_2' id='label_37_3_2' class='gform-field-label gform-field-label--type-inline'>Between 4 years and 7 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Between 7 years and 10 years'  id='choice_37_3_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_3' id='label_37_3_3' class='gform-field-label gform-field-label--type-inline'>Between 7 years and 10 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Over 10 years'  id='choice_37_3_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_4' id='label_37_3_4' class='gform-field-label gform-field-label--type-inline'>Over 10 years<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Type of relationship (Check all that apply):<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_37_27'>Please note that we cannot accept reference completed by family members of the applicant.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_27'>\n\t\t\t<div class='gchoice gchoice_37_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Supervised applicant'  id='choice_37_27_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_37_27\"   \/>\n\t\t\t\t\t<label for='choice_37_27_0' id='label_37_27_0' class='gform-field-label gform-field-label--type-inline'>Supervised applicant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Worked with applicant'  id='choice_37_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_1' id='label_37_27_1' class='gform-field-label gform-field-label--type-inline'>Worked with applicant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Friend'  id='choice_37_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_2' id='label_37_27_2' class='gform-field-label gform-field-label--type-inline'>Friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Neighbor'  id='choice_37_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_3' id='label_37_27_3' class='gform-field-label gform-field-label--type-inline'>Neighbor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Other'  id='choice_37_27_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_4' id='label_37_27_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_12'><span class='gform-field-label__text'>Can you share an example of a time they went above and beyond to help someone in need?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_37_12' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_35'><span class='gform-field-label__text'>What were some major accomplishments achieved while working with you?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_37_35' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_43\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_43'><span class='gform-field-label__text'>How would you describe their ability to handle stressful situations?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_37_43' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_44'><span class='gform-field-label__text'>What strengths have you observed in their caregiving role?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_37_44' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_37_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>If the applicant was a former employee, would you rehire this person?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_36'>\n\t\t\t<div class='gchoice gchoice_37_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_37_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_36_0' id='label_37_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_37_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_36_1' id='label_37_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='N\/A'  id='choice_37_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_36_2' id='label_37_36_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_37'><span class='gform-field-label__text'>Would you recommend this applicant for the Direct Care Worker position? Please share why.<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_37_37' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">By signing and submitting this form, I attest that I am the individual that completed this reference for the applicant listed above. I also agree to be contacted via the phone or email that I listed if further verification or information is needed by the UCP of Central Arizona administrative team<\/h3><\/div><div id=\"field_37_41\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_41'><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_41' id='input_37_41_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_37_41_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_37_41' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/ucpofcentralaz.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_37_41_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img decoding=\"async\" id=\"input_37_41_resetbutton\" src=\"data:image\/png;base64,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\" style=\"cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent\" alt=\"Clear Signature\" title=\"\"><\/div><input type='hidden' id='input_37_41_data' name='input_37_41_data' value=''><\/div><\/div><div id=\"field_37_42\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_42'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_37_42'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_42'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_37_42' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_37_42' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_37_42' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_37' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_37' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_37' id='gform_theme_37' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_37' id='gform_style_settings_37' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_37' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='37' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='EnlGzn7N1Jr4oLv24WHUyfzE0Q1FzFRufU6MBeUWf1PRSeIFmSoJZAevz0YBqOsjyHYELmZbRlRq4+hVECSqZge1fhu7ZmXhxQnTEOuvNP5go9Y=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_37' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_37' id='gform_target_page_number_37' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_37' id='gform_source_page_number_37' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><div class=\"vc_empty_space\"   style=\"height: 80px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"UCP HCBS Reference Form Please complete the questions listed below. Keep in mind that direct care worker services are typically performed unsupervised in the home of a person with physical or developmental disabilities. UCP of Central Arizona will maintain strict confidentiality of your responses in accordance with the law. We appreciate your time and effort. [...]","protected":false},"author":15,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-full-width.php","meta":{"nf_dc_page":"","footnotes":""},"class_list":["post-14102","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/14102","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/comments?post=14102"}],"version-history":[{"count":4,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/14102\/revisions"}],"predecessor-version":[{"id":14113,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/14102\/revisions\/14113"}],"wp:attachment":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/media?parent=14102"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}