{"id":505,"date":"2021-07-12T18:08:00","date_gmt":"2021-07-12T18:08:00","guid":{"rendered":"https:\/\/driscoll.gomohealth.care\/?page_id=505"},"modified":"2021-07-12T18:09:39","modified_gmt":"2021-07-12T18:09:39","slug":"ccc","status":"publish","type":"page","link":"https:\/\/driscoll.gomohealth.care\/es\/ccc\/","title":{"rendered":"Encuesta del Centro Comunitario de Conexi\u00f3n"},"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 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><script type=\"text\/javascript\">var 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 e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_32' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_32'  action='\/es\/wp-json\/wp\/v2\/pages\/505' ><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_32\" \/>\n                        <div class='gform_body gform-body'><ul id='gform_fields_32' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_32_32\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_32\"><div class='ginput_container ginput_container_text'><input name='input_32' id='input_32_32' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_32_33\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_33\"><div class='ginput_container ginput_container_text'><input name='input_33' id='input_32_33' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/driscoll.gomohealth.care\/es\/wp-json\/wp\/v2\/pages\/505' \/><\/div><\/li><li id=\"field_32_1\"  class=\"gfield mt_25 gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_1\"><p>El objetivo de este cuestionario es recolectar informaci\u00f3n sobre su familia. Por favor, lea y responda todas las preguntas. Toda la informaci\u00f3n otorgada es confidencial y no quedar\u00e1 a disposici\u00f3n de ninguna otra persona sin su consentimiento por escrito.<\/p>\n \n<p>* = requerido<\/p><\/li><li id=\"field_32_2\"  class=\"gfield mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_2\"><label class='gfield_label' for='input_32_2' >Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input readonly='readonly' name='input_2' id='input_32_2' type='text' value='05\/26\/2026' class='gpro-disabled-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_32_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_32_2_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <input type=\"hidden\" id=\"gwro_hidden_capture_32_2\" name=\"gwro_hidden_capture_32_2\" value=\"05\/26\/2026\" class=\"gf-default-disabled\" \/><\/div>\n                        <input readonly='readonly' type='hidden' id='gforms_calendar_icon_input_32_2' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_32_3\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_3\"><label class='gfield_label' for='input_32_3' >Seleccione el Centro Comunitario de Conexi\u00f3n que visit\u00f3.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_32_3' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>-- Please Select --<\/option><option value='Aransas County- Esperanza de Tejas- Mobile Community Connection Room' >Aransas County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Bee County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room' >Bee County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room<\/option><option value='Brooks County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room' >Brooks County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room<\/option><option value='Cameron County- El Centro Cultural Community Center' >Cameron County- El Centro Cultural Community Center<\/option><option value='Cameron County- Esperanza de Tejas- Mobile Community Connection Center' >Cameron County- Esperanza de Tejas- Mobile Community Connection Center<\/option><option value='Cameron - Prospera - Cunningham Manor Apartments' >Cameron - Prospera - Cunningham Manor Apartments<\/option><option value='Duval County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room' >Duval County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room<\/option><option value='Hidalgo County- Esperanza de Tejas- Mobile Community Connection Room' >Hidalgo County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Hidalgo County- The Endowment Center San Carlos' >Hidalgo County- The Endowment Center San Carlos<\/option><option value='Jim Hogg County- Esperanza de Tejas- Mobile Community Connection Center' >Jim Hogg County- Esperanza de Tejas- Mobile Community Connection Center<\/option><option value='Jim Wells County- Esperanza de Tejas- Mobile Community Connection Room' >Jim Wells County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Kleberg County- Esperanza de Tejas- Mobile Community Connection Room' >Kleberg County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Live Oak County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room' >Live Oak County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room<\/option><option value='Nueces County- Esperanza de Tejas- Mobile Community Connection Room' >Nueces County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Nueces - Prospera - Lexington Manor Apartments' >Nueces - Prospera - Lexington Manor Apartments<\/option><option value='Refugio County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room' >Refugio County \u2013 Esperanza de Tejas \u2013 Mobile Community Connection Room<\/option><option value='San Patricio County- Esperanza de Tejas- Mobile Community Connection Room' >San Patricio County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Starr County- Esperanza de Tejas- Mobile Community Connection Center' >Starr County- Esperanza de Tejas- Mobile Community Connection Center<\/option><option value='Victoria County- Esperanza de Tejas- Mobile Community Connection Center' >Victoria County- Esperanza de Tejas- Mobile Community Connection Center<\/option><option value='Victoria County- Victoria ISD' >Victoria County- Victoria ISD<\/option><option value='Webb County- Esperanza de Tejas- Mobile Community Connection Room' >Webb County- Esperanza de Tejas- Mobile Community Connection Room<\/option><option value='Willacy County- Esperanza de Tejas- Mobile Community Connection Center' >Willacy County- Esperanza de Tejas- Mobile Community Connection Center<\/option><option value='Zapata County- Esperanza de Tejas- Mobile Community Connection Center' >Zapata County- Esperanza de Tejas- Mobile Community Connection Center<\/option><\/select><\/div><\/li><li id=\"field_32_4\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_4\"><label class='gfield_label' for='input_32_4' >Ciudad donde vives:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_32_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_5\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_5\"><label class='gfield_label' for='input_32_5' >C\u00f3digo Postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_32_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_35\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_35\"><label class='gfield_label' for='input_32_35' >\u00bfCu\u00e1l es tu edad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_32_35' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_36\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_36\"><label class='gfield_label'  >\u00bfEst\u00e1s embarazada actualmente?<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_32_36'>\n\t\t\t<li class='gchoice gchoice_32_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_32_36_0'    \/>\n\t\t\t\t<label for='choice_32_36_0' id='label_32_36_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_32_36_1'    \/>\n\t\t\t\t<label for='choice_32_36_1' id='label_32_36_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_37\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_37\"><label class='gfield_label'  >\u00bfTiene hijos menores de 18 a\u00f1os?<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_32_37'>\n\t\t\t<li class='gchoice gchoice_32_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Yes'  id='choice_32_37_0'    \/>\n\t\t\t\t<label for='choice_32_37_0' id='label_32_37_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='No'  id='choice_32_37_1'    \/>\n\t\t\t\t<label for='choice_32_37_1' id='label_32_37_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_38\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_38\"><label class='gfield_label' for='input_32_38' >\u00bfCuantos?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_32_38' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_39\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_39\"><label class='gfield_label'  >\u00bf Es usted el cuidador principal de los ni\u00f1os?<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_32_39'>\n\t\t\t<li class='gchoice gchoice_32_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_32_39_0'    \/>\n\t\t\t\t<label for='choice_32_39_0' id='label_32_39_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_32_39_1'    \/>\n\t\t\t\t<label for='choice_32_39_1' id='label_32_39_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_40\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_40\"><label class='gfield_label' for='input_32_40' >\u00bfCu\u00e1ntas personas viven en tu casa?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_32_40' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_41\"  class=\"gfield mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_41\"><label class='gfield_label gfield_label_before_complex'  >\u00bfUsted o alguien en su hogar tiene alguno de los siguientes? Seleccione todos los que correspondan.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_32_41'><li class='gchoice gchoice_32_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Special needs'  id='choice_32_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_41_1' id='label_32_41_1'>Necesidades especiales<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='Behavioral health'  id='choice_32_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_41_2' id='label_32_41_2'>Salud conductual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Chronic illness'  id='choice_32_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_41_3' id='label_32_41_3'>Enfermedad cr\u00f3nica<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_43\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_43\"><label class='gfield_label'  >\u00bfQuien tiene necesidades especiales?<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_32_43'>\n\t\t\t<li class='gchoice gchoice_32_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Me'  id='choice_32_43_0'    \/>\n\t\t\t\t<label for='choice_32_43_0' id='label_32_43_0'>Yo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='A household member'  id='choice_32_43_1'    \/>\n\t\t\t\t<label for='choice_32_43_1' id='label_32_43_1'>Un miembro del hogar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_43_2'>\n\t\t\t\t<input name='input_43' type='radio' value='A household member and me'  id='choice_32_43_2'    \/>\n\t\t\t\t<label for='choice_32_43_2' id='label_32_43_2'>Un miembro del hogar y yo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_44\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_44\"><label class='gfield_label'  >\u00bfQuien tiene salud conductual?<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_32_44'>\n\t\t\t<li class='gchoice gchoice_32_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Me'  id='choice_32_44_0'    \/>\n\t\t\t\t<label for='choice_32_44_0' id='label_32_44_0'>Yo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='A household member'  id='choice_32_44_1'    \/>\n\t\t\t\t<label for='choice_32_44_1' id='label_32_44_1'>Un miembro del hogar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_44_2'>\n\t\t\t\t<input name='input_44' type='radio' value='A household member and me'  id='choice_32_44_2'    \/>\n\t\t\t\t<label for='choice_32_44_2' id='label_32_44_2'>Un miembro del hogar y yo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_45\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_45\"><label class='gfield_label'  >\u00bfQuien tiene enfermedad cr\u00f3nica?<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_32_45'>\n\t\t\t<li class='gchoice gchoice_32_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Me'  id='choice_32_45_0'    \/>\n\t\t\t\t<label for='choice_32_45_0' id='label_32_45_0'>Yo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='A household member'  id='choice_32_45_1'    \/>\n\t\t\t\t<label for='choice_32_45_1' id='label_32_45_1'>Un miembro del hogar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_45_2'>\n\t\t\t\t<input name='input_45' type='radio' value='A household member and me'  id='choice_32_45_2'    \/>\n\t\t\t\t<label for='choice_32_45_2' id='label_32_45_2'>Un miembro del hogar y yo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_46\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_32_46\"><label class='gfield_label gfield_label_before_complex'  >\u00bfUsted o un miembro de su hogar tiene actualmente alguno de los tipos de asistencia que se indican a continuaci\u00f3n? Seleccione todos los que correspondan.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_32_46'><li class='gchoice gchoice_32_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Medicaid'  id='choice_32_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_1' id='label_32_46_1'>Medicaid<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Medicare'  id='choice_32_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_2' id='label_32_46_2'>Medicare<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.3' type='checkbox'  value='CHIP-Children&#039;s Medicaid'  id='choice_32_46_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_3' id='label_32_46_3'>CHIP - Medicaid para ni\u00f1os<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.4' type='checkbox'  value='Housing Assistance'  id='choice_32_46_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_4' id='label_32_46_4'>Asistencia para la vivienda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.5' type='checkbox'  value='TANF - Temporary Assistance for Needy Families'  id='choice_32_46_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_5' id='label_32_46_5'>TANF - Asistencia temporal para familias necesitadas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.6' type='checkbox'  value='ECI \u2013 Early Childhood Intervention'  id='choice_32_46_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_6' id='label_32_46_6'>ECI \u2013 intervenci\u00f3n en la primera infancia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.7' type='checkbox'  value='Federal Assistance from School District'  id='choice_32_46_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_7' id='label_32_46_7'>Asistencia federal del distrito escolar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.8' type='checkbox'  value='Head Start program'  id='choice_32_46_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_8' id='label_32_46_8'>Programa Head Start<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.9' type='checkbox'  value='SNAP - Food Stamps'  id='choice_32_46_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_9' id='label_32_46_9'>SNAP \u2013 cupones de alimentos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.11' type='checkbox'  value='WIC'  id='choice_32_46_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_11' id='label_32_46_11'>WIC<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.12' type='checkbox'  value='My family and I do not receive any assistance'  id='choice_32_46_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_12' id='label_32_46_12'>Mi familia ni yo recibimos ninguna ayuda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_46_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.13' type='checkbox'  value='Other'  id='choice_32_46_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_46_13' id='label_32_46_13'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_47\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_47\"><label class='gfield_label' for='input_32_47' >Seleccion\u00f3 &quot;Otro&quot;, describa el hogar:<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_32_47' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_48\"  class=\"gfield mt_25 field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_32_48\"><label class='gfield_label gfield_label_before_complex'  >\u00bfNecesita una remisi\u00f3n para alguno de los siguientes? Seleccione todos los que correspondan.<\/label><div class='gfield_description' id='gfield_description_32_48'><span class=\"custom-description-one\">La comunidad tiene una hoja de referencia donde podemos conectarlo con los servicios. Pregunte al personal de la sala comunitaria.<\/span><\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_32_48'><li class='gchoice gchoice_32_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Domestic Violence Assistance'  id='choice_32_48_1'   aria-describedby=\"gfield_description_32_48\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_1' id='label_32_48_1'>Asistencia por violencia dom\u00e9stica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Housing Assistance'  id='choice_32_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_2' id='label_32_48_2'>Asistencia para la vivienda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='Food assistance'  id='choice_32_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_3' id='label_32_48_3'>Asistencia alimentaria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Clothing assistance'  id='choice_32_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_4' id='label_32_48_4'>Asistencia de ropa<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='Childcare assistance'  id='choice_32_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_5' id='label_32_48_5'>Asistencia de cuidado infantil<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.6' type='checkbox'  value='Medicaid\/CHIP assistance - renewal'  id='choice_32_48_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_6' id='label_32_48_6'>Asistencia de Medicaid\/CHIP - renovaci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.7' type='checkbox'  value='Continuing education; GED'  id='choice_32_48_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_7' id='label_32_48_7'>Educaci\u00f3n continua; GED<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.8' type='checkbox'  value='Internet access'  id='choice_32_48_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_8' id='label_32_48_8'>Acceso a internet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.9' type='checkbox'  value='Transportation assistance'  id='choice_32_48_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_9' id='label_32_48_9'>Acceso a transporte<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.11' type='checkbox'  value='Utilities assistance'  id='choice_32_48_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_11' id='label_32_48_11'>Asistencia de servicios p\u00fablicos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.12' type='checkbox'  value='Emotional parent support'  id='choice_32_48_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_12' id='label_32_48_12'>Apoyo emocional para padres<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_48_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.13' type='checkbox'  value='Other'  id='choice_32_48_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_48_13' id='label_32_48_13'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_49\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_49\"><label class='gfield_label' for='input_32_49' >Seleccion\u00f3 &quot;Otro&quot;, describa el hogar:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_32_49' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_50\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_50\"><label class='gfield_label'  >\u00bfEs usted o alguien en su hogar un trabajador migrante?<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_32_50'>\n\t\t\t<li class='gchoice gchoice_32_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_32_50_0'    \/>\n\t\t\t\t<label for='choice_32_50_0' id='label_32_50_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_32_50_1'    \/>\n\t\t\t\t<label for='choice_32_50_1' id='label_32_50_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_52\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_52\"><label class='gfield_label'  >\u00bfCu\u00e1l es tu situaci\u00f3n laboral?<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_32_52'>\n\t\t\t<li class='gchoice gchoice_32_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Fulltime'  id='choice_32_52_0'    \/>\n\t\t\t\t<label for='choice_32_52_0' id='label_32_52_0'>Tiempo completo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='Part time'  id='choice_32_52_1'    \/>\n\t\t\t\t<label for='choice_32_52_1' id='label_32_52_1'>Tiempo parcial<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_52_2'>\n\t\t\t\t<input name='input_52' type='radio' value='Not working'  id='choice_32_52_2'    \/>\n\t\t\t\t<label for='choice_32_52_2' id='label_32_52_2'>No funciona<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_52_3'>\n\t\t\t\t<input name='input_52' type='radio' value='Retired'  id='choice_32_52_3'    \/>\n\t\t\t\t<label for='choice_32_52_3' id='label_32_52_3'>Retirado<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_51\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_51\"><label class='gfield_label'  >\u00bfCu\u00e1l es su situaci\u00f3n de vivienda?<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_32_51'>\n\t\t\t<li class='gchoice gchoice_32_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='Own'  id='choice_32_51_0'    \/>\n\t\t\t\t<label for='choice_32_51_0' id='label_32_51_0'>Propio<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='Rent'  id='choice_32_51_1'    \/>\n\t\t\t\t<label for='choice_32_51_1' id='label_32_51_1'>Alquilar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_51_2'>\n\t\t\t\t<input name='input_51' type='radio' value='Staying with friends\/family'  id='choice_32_51_2'    \/>\n\t\t\t\t<label for='choice_32_51_2' id='label_32_51_2'>Quedarse con amigos \/ familia<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_51_3'>\n\t\t\t\t<input name='input_51' type='radio' value='Homeless or displaced'  id='choice_32_51_3'    \/>\n\t\t\t\t<label for='choice_32_51_3' id='label_32_51_3'>Sin hogar o deplazados<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_53\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_53\"><label class='gfield_label'  >\u00bfQu\u00e9 idioma hablas en 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_32_53'>\n\t\t\t<li class='gchoice gchoice_32_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='English'  id='choice_32_53_0'    \/>\n\t\t\t\t<label for='choice_32_53_0' id='label_32_53_0'>Ingl\u00e9s<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='Spanish'  id='choice_32_53_1'    \/>\n\t\t\t\t<label for='choice_32_53_1' id='label_32_53_1'>Espa\u00f1ol<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_53_2'>\n\t\t\t\t<input name='input_53' type='radio' value='Both English\/Spanish'  id='choice_32_53_2'    \/>\n\t\t\t\t<label for='choice_32_53_2' id='label_32_53_2'>Ambos ingl\u00e9s \/ espa\u00f1ol<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_53_3'>\n\t\t\t\t<input name='input_53' type='radio' value='Other'  id='choice_32_53_3'    \/>\n\t\t\t\t<label for='choice_32_53_3' id='label_32_53_3'>Otro<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_54\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_54\"><label class='gfield_label' for='input_32_54' >Seleccion\u00f3 &quot;Otro&quot;, describa el hogar:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_32_54' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_55\"  class=\"gfield mt_25 field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_32_55\"><label class='gfield_label gfield_label_before_complex'  >\u00bfSe beneficiar\u00eda de alguno de los siguientes temas de salud o programas sociales? Seleccione todos los que correspondan.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_32_55'><li class='gchoice gchoice_32_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Behavioral health'  id='choice_32_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_1' id='label_32_55_1'>Salud conductual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Mental health'  id='choice_32_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_2' id='label_32_55_2'>Salud mental<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Chronic illness'  id='choice_32_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_3' id='label_32_55_3'>Enfermedad cr\u00f3nica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='Maternal health'  id='choice_32_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_4' id='label_32_55_4'>Salud maternal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='Long term health'  id='choice_32_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_5' id='label_32_55_5'>Salud a largo plazo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='Diabetes'  id='choice_32_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_6' id='label_32_55_6'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.7' type='checkbox'  value='Asthma'  id='choice_32_55_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_7' id='label_32_55_7'>Asma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.8' type='checkbox'  value='Weight loss program'  id='choice_32_55_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_8' id='label_32_55_8'>Programa de adelgazamiento<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.9' type='checkbox'  value='Cooking classes'  id='choice_32_55_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_9' id='label_32_55_9'>Clases de cocina<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.11' type='checkbox'  value='Parenting classes'  id='choice_32_55_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_11' id='label_32_55_11'>Clase para padres<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.12' type='checkbox'  value='Physical education class'  id='choice_32_55_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_12' id='label_32_55_12'>Clase de educaci\u00f3n f\u00edsica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_55_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.13' type='checkbox'  value='Other'  id='choice_32_55_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_55_13' id='label_32_55_13'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_56\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_56\"><label class='gfield_label' for='input_32_56' >Seleccion\u00f3 &quot;Otro&quot;, describa el hogar:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_32_56' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_60\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_60\"><label class='gfield_label'  >\u00bfRecibi\u00f3 una hoja de referencia con informaci\u00f3n sobre programas comunitarios del personal que lo ayud\u00f3 hoy?<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_32_60'>\n\t\t\t<li class='gchoice gchoice_32_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Yes'  id='choice_32_60_0'    \/>\n\t\t\t\t<label for='choice_32_60_0' id='label_32_60_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='No'  id='choice_32_60_1'    \/>\n\t\t\t\t<label for='choice_32_60_1' id='label_32_60_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_61\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_61\"><p>Si la respuesta es No: P\u00eddale al personal que le proporcione una copia. Esta hoja tendr\u00e1 informaci\u00f3n sobre otros programas que pueden ayudarlo con los servicios.<\/p><\/li><li id=\"field_32_57\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_57\"><label class='gfield_label'  >\u00bfQui\u00e9n lo refiri\u00f3 a la sala comunitaria de Driscoll?<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_32_57'>\n\t\t\t<li class='gchoice gchoice_32_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Family\/Friend'  id='choice_32_57_0'    \/>\n\t\t\t\t<label for='choice_32_57_0' id='label_32_57_0'>Familia \/ amigo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Organization'  id='choice_32_57_1'    \/>\n\t\t\t\t<label for='choice_32_57_1' id='label_32_57_1'>Organizaci\u00f3n<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_58\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_58\"><label class='gfield_label' for='input_32_58' >Seleccion\u00f3 &quot;Organizaci\u00f3n&quot;, describa el hogar:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_32_58' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_59\"  class=\"gfield mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_59\"><label class='gfield_label' for='input_32_59' >\u00bfQu\u00e9 otros art\u00edculos \/ suministros le gustar\u00eda ver en la sala comunitaria?<\/label><div 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value=\"90\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-0{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:100% !important;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-0{width:100% !important;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body 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