if (window.location.protocol != "https:" && window.location.href.indexOf("formulate") == -1 && "False" === "True") {
    window.location.href = "https:" + window.location.href.substring(window.location.protocol.length);
}

var fbScriptTag = document.getElementsByClassName("6a3afb1a-4285-453b-bbfa-cce939109205"),
    fbBodyTag = document.body,
    fbHeadTag = document.head,
    fbIsTestResponse = 'False',
    fbEnableInstaMedScript = 'False',
    fbRenderContainer = document.createElement("div"),
    fbRenderedCssContainer = document.createElement("div"),
    fbConfigScript = document.createElement("script"),
    fbRequireJSScript = document.createElement("script"),
    fbInstaMedJSScript = document.createElement("script"),
    fbGeoCaptchaCallback = document.createElement("script"),
    fbGeoReCaptchaCallback = document.createElement("script"),
    fbFormulateRenderer = document.createElement("script"),
    fbRenderedIntegrations = document.createElement("script"),
    fbRenderedScripts = document.createElement("script"),
    fbAutoPopulateFromQueryString = document.createElement("script"),
    fbEmbeddedCss = "",
    renderedScripts = '';

if(fbScriptTag.length === 0) {
    fbScriptTag = document.querySelector("script[src*='6a3afb1a-4285-453b-bbfa-cce939109205']");
} else {
    fbScriptTag = fbScriptTag[0];
}

fbRenderContainer.id = "formRenderContainer";
fbRenderContainer.className = " fbRenderContainer fbRenderContainer_6a3afb1a-4285-453b-bbfa-cce939109205";
fbRenderedCssContainer.id = "fbRenderedCssContainer";

fbConfigScript.type = "text/javascript";
fbRequireJSScript.type = "text/javascript";
fbInstaMedJSScript.type = "text/javascript";
fbGeoCaptchaCallback.type = "text/javascript";
fbGeoReCaptchaCallback.type = "text/javascript";
fbFormulateRenderer.type = "text/javascript";
fbRenderedIntegrations.type = "text/javascript";
fbRenderedScripts.type = "text/javascript";
fbAutoPopulateFromQueryString.type = "text/javascript";

fbRequireJSScript.src = "https://formulate.geonetric.com/Scripts/require.min.js";
fbInstaMedJSScript.src = "https://formulate.geonetric.com/Scripts/vendor/instamed/token.js";
fbInstaMedJSScript.id = "instamed-sdk";
fbGeoCaptchaCallback.src = "https://formulate.geonetric.com/Scripts/geo-captcha-callback.js";
fbGeoReCaptchaCallback.src = "https://www.google.com/recaptcha/api.js?onload=geoFbCaptchaCallback&render=6LdxkTEpAAAAAMKbkhz8-INpQis_mvSaIXnoyC2V";
fbFormulateRenderer.src = "https://formulate.geonetric.com/Scripts/require/formulate-renderer.js?embeddedCssType=0&isTestResponse=False&hasGoogleAnalytics=False";
fbFormulateRenderer.id = "formulateRendererScript";
fbAutoPopulateFromQueryString.src = "https://formulate.geonetric.com/Scripts/auto-populate-from-query-string.js";

if (fbEnableInstaMedScript === 'True') {
    fbInstaMedJSScript.setAttribute("data-displaymode", "embedded");
    fbInstaMedJSScript.setAttribute("data-environment", "UAT");
    fbInstaMedJSScript.setAttribute("data-mobiledisplaymode", "embedded");
}

fbGeoCaptchaCallback.onload = function() {
    if(document.querySelectorAll('.geo-fb-recaptcha').length > 0)
    {
        fbBodyTag.appendChild(fbGeoReCaptchaCallback);
    }
}

fbRequireJSScript.addEventListener("load", function() {
    fbBodyTag.appendChild(fbFormulateRenderer);
    fbBodyTag.appendChild(fbAutoPopulateFromQueryString);
});

fbFormulateRenderer.addEventListener("load", function () {
    initFormBuilderForm();
});

var embeddedCssType = 0
switch (embeddedCssType) {
    case 1:
        fbEmbeddedCss = '<link href=\"https://formulate.geonetric.com/Content/bootstrap.min.css\" rel=\"stylesheet\"><link href=\"https://formulate.geonetric.com/Content/embedded/font-awesome/css/font-awesome.min.css\" rel=\"stylesheet\"><link href=\"https://formulate.geonetric.com/Content/embedded/embedded.css\" rel=\"stylesheet\">';
        break;
    case 2:
        fbEmbeddedCss = '';
        break;
    default:
        fbEmbeddedCss = '<link href=\"https://formulate.geonetric.com/Content/embedded/font-awesome/css/font-awesome.min.css\" rel=\"stylesheet\"><link href=\"https://formulate.geonetric.com/Content/embedded/embedded.css\" rel=\"stylesheet\">';
}

if (fbIsTestResponse === 'True') {
    fbRenderContainer.setAttribute('data-test-mode', 'true');
} else {
    fbRenderContainer.setAttribute('data-test-mode', 'false');
}

fbRenderContainer.innerHTML = "<div id=\'formContainer_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'fbFormContainer fbFormContainer_6a3afb1a-4285-453b-bbfa-cce939109205 BlockLabels hidden\'>\
<p>Required fields are marked with <span class=\'fb-required\'>*</span></p>\
<input type=\'hidden\' name=\'formId\' id=\'formId\' value=\'6a3afb1a-4285-453b-bbfa-cce939109205\' />\
<input type=\'hidden\' name=\'formName\' id=\'formName\' value=\'Community Health Worker Intake\' />\
<input type=\'hidden\' name=\'formVersion\' value=\'10\' id=\'formVersion\' />\
<input type=\'hidden\' name=\'organizationId\' id=\'organizationId\' value=\'69c8ce7d-7b4e-40fd-a0d7-a6735511f008\' />\
<input type=\'hidden\' name=\'responseId\' id=\'responseId\' value=\'c9123962-8876-4699-b553-2b0117273aef\' />\
<input type=\'hidden\' name=\'formBaseUrl\' id=\'formBaseUrl\' value=\'https://formulate.geonetric.com\' />\
\
\
<p>Are you interested in receiving one-on-one support from a Community Health Worker to overcome barriers and reach your health goals? This is a free and voluntary program. The only requirement to enroll is that you be willing to set a health goal and commit to working toward that goal while enrolled in the program.</p><p>Please complete the questions in this survey to the best of your ability and someone will reach out to you or the individual you are referring to discuss their referral.</p>\
                        <fieldset class=\'fb-fieldset \'>\
                            <legend class=\'fb-legend \'>Your Name</legend>\
                            \
                            <div class=\'row\'>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField2_6a3afb1a-4285-453b-bbfa-cce939109205First\'>First Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField2_6a3afb1a-4285-453b-bbfa-cce939109205First\' name=\'FormField2_6a3afb1a-4285-453b-bbfa-cce939109205First\' type=\'text\' data-export-label=\'Your_Name_First_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'First Name is required.\' />\
                        \
                    </div>\
                </div>\
                                </div>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField2_6a3afb1a-4285-453b-bbfa-cce939109205Last\'>Last Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField2_6a3afb1a-4285-453b-bbfa-cce939109205Last\' name=\'FormField2_6a3afb1a-4285-453b-bbfa-cce939109205Last\' type=\'text\' data-export-label=\'Your_Name_Last_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'Last Name is required.\' />\
                        \
                    </div>\
                </div>\
                                </div>\
                            </div>\
                        </fieldset><div class=\'form-group\'><label for=\'FormField8_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'control-label  \'>What is your relationship to the person being referred?</label><div><select  name=\'FormField8_6a3afb1a-4285-453b-bbfa-cce939109205\' id=\'FormField8_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'Relationship\' ><option value=\'Self\' selected>Self</option><option value=\'Friend\'>Friend</option><option value=\'Family Member\'>Family Member</option><option value=\'Physician\'>Physician</option><option value=\'Case Manager/Social Worker\'>Case Manager/Social Worker</option><option value=\'Community Member\'>Community Member</option><option value=\'Other\'>Other</option></select></div></div>\
                        <fieldset class=\'fb-fieldset \'>\
                            <legend class=\'fb-legend \'>What is the name of the individual being referred? If you are submitting this form for yourself, type SAME in the lines below.</legend>\
                            \
                            <div class=\'row\'>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField9_6a3afb1a-4285-453b-bbfa-cce939109205First\'>First Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField9_6a3afb1a-4285-453b-bbfa-cce939109205First\' name=\'FormField9_6a3afb1a-4285-453b-bbfa-cce939109205First\' type=\'text\' data-export-label=\'name_First_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'First Name is required.\' />\
                        \
                    </div>\
                </div>\
                                </div>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField9_6a3afb1a-4285-453b-bbfa-cce939109205Last\'>Last Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField9_6a3afb1a-4285-453b-bbfa-cce939109205Last\' name=\'FormField9_6a3afb1a-4285-453b-bbfa-cce939109205Last\' type=\'text\' data-export-label=\'name_Last_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'Last Name is required.\' />\
                        \
                    </div>\
                </div>\
                                </div>\
                            </div>\
                        </fieldset>\
                <fieldset class=\'fb-fieldset \'>\
                    <legend class=\'fb-legend \'>Address</legend>\
                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Line1\'>Line 1<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Line1\' name=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Line1\' type=\'text\' data-export-label=\'Address_Line1\'  required data-msg-required=\'Address Line 1 is required.\' autocomplete=\'street-address\'  />\
                    </div>\
                </div>\
                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Line2\'>Line 2</label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Line2\' name=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Line2\' type=\'text\' data-export-label=\'Address_Line2\'     />\
                    </div>\
                </div>\
                    <div class=\'row\'>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_City\'>City<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_City\' name=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_City\' type=\'text\' data-export-label=\'Address_City\'  required data-msg-required=\'Address City is required.\' autocomplete=\'locality\'  />\
                    </div>\
                </div>\
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_State\'>State<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <select class=\'form-control\' name=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_State\' id=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_State\' autocomplete=\'region\' required=\'required\' data-msg-required=\'Address State is required.\' data-export-label=\'Address_State\' >\
                            <option value=\'\'>( Please Select )</option>\
                            <option value=\'AL\'>Alabama</option>\
                            <option value=\'AK\'>Alaska</option>\
                            <option value=\'AZ\'>Arizona</option>\
                            <option value=\'AR\'>Arkansas</option>\
                            <option value=\'CA\'>California</option>\
                            <option value=\'CO\'>Colorado</option>\
                            <option value=\'CT\'>Connecticut</option>\
                            <option value=\'DE\'>Delaware</option>\
                            <option value=\'DC\'>District Of Columbia</option>\
                            <option value=\'FL\'>Florida</option>\
                            <option value=\'GA\'>Georgia</option>\
                            <option value=\'HI\'>Hawaii</option>\
                            <option value=\'ID\'>Idaho</option>\
                            <option value=\'IL\'>Illinois</option>\
                            <option value=\'IN\'>Indiana</option>\
                            <option value=\'IA\'>Iowa</option>\
                            <option value=\'KS\'>Kansas</option>\
                            <option value=\'KY\'>Kentucky</option>\
                            <option value=\'LA\'>Louisiana</option>\
                            <option value=\'ME\'>Maine</option>\
                            <option value=\'MD\'>Maryland</option>\
                            <option value=\'MA\'>Massachusetts</option>\
                            <option value=\'MI\'>Michigan</option>\
                            <option value=\'MN\'>Minnesota</option>\
                            <option value=\'MS\'>Mississippi</option>\
                            <option value=\'MO\'>Missouri</option>\
                            <option value=\'MT\'>Montana</option>\
                            <option value=\'NE\'>Nebraska</option>\
                            <option value=\'NV\'>Nevada</option>\
                            <option value=\'NH\'>New Hampshire</option>\
                            <option value=\'NJ\'>New Jersey</option>\
                            <option value=\'NM\'>New Mexico</option>\
                            <option value=\'NY\'>New York</option>\
                            <option value=\'NC\'>North Carolina</option>\
                            <option value=\'ND\'>North Dakota</option>\
                            <option value=\'OH\'>Ohio</option>\
                            <option value=\'OK\'>Oklahoma</option>\
                            <option value=\'OR\'>Oregon</option>\
                            <option value=\'PA\'>Pennsylvania</option>\
                            <option value=\'RI\'>Rhode Island</option>\
                            <option value=\'SC\'>South Carolina</option>\
                            <option value=\'SD\'>South Dakota</option>\
                            <option value=\'TN\'>Tennessee</option>\
                            <option value=\'TX\'>Texas</option>\
                            <option value=\'UT\'>Utah</option>\
                            <option value=\'VT\'>Vermont</option>\
                            <option value=\'VA\'>Virginia</option>\
                            <option value=\'WA\'>Washington</option>\
                            <option value=\'WV\'>West Virginia</option>\
                            <option value=\'WI\'>Wisconsin</option>\
                            <option value=\'WY\'>Wyoming</option>\
                        </select>\
                    </div>\
                </div>\
                \
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Zip\'>Zip<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Zip\' name=\'FormField3_6a3afb1a-4285-453b-bbfa-cce939109205_Zip\' type=\'text\' data-export-label=\'Address_Zip\'  required data-msg-required=\'Address Zip is required.\' autocomplete=\'postal-code\' data-rule-zipCode=\'true\' />\
                    </div>\
                </div>\
                        </div>\
                    </div>\
                </fieldset><div class=\'form-group\'><label for=\'FormField4_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'control-label  \'>Best Phone Number to Reach You<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField4_6a3afb1a-4285-453b-bbfa-cce939109205\' id=\'FormField4_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Best Phone Number to Reach You is required.\' data-export-label=\'Best_Phone_Number_to_Reach_You\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField5_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'control-label  \'>Email</label><div><input type=\'email\' name=\'FormField5_6a3afb1a-4285-453b-bbfa-cce939109205\' id=\'FormField5_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Email\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField10_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'control-label  \'>Where is your primary care office?</label><div><select  name=\'FormField10_6a3afb1a-4285-453b-bbfa-cce939109205\' id=\'FormField10_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'Practice\' ><option value=\'\' selected>( Please Select )</option><option value=\'Augusta Family Medicine\'>Augusta Family Medicine</option><option value=\'Elmwood Primary Care\'>Elmwood Primary Care</option><option value=\'Family Medicine Institute\'>Family Medicine Institute</option><option value=\'Four Season Family Practice \'>Four Season Family Practice </option><option value=\'Gardiner Family Medicine\'>Gardiner Family Medicine</option><option value=\'Great Oaks Family Practice\'>Great Oaks Family Practice</option><option value=\'Maine Dartmouth Family Medicine\'>Maine Dartmouth Family Medicine</option><option value=\'MaineGeneral Internal Medicine\'>MaineGeneral Internal Medicine</option><option value=\'Oakland Family Medicine\'>Oakland Family Medicine</option><option value=\'Thayer Internal Medicine\'>Thayer Internal Medicine</option><option value=\'Winthrop Family Medicine\'>Winthrop Family Medicine</option><option value=\'I am not established with a primary care practice.\'>I am not established with a primary care practice.</option><option value=\'My primary care practice isn&#39;t listed.\'>My primary care practice isn&#39;t listed.</option></select></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Do you have any of the following health conditions? Check all that apply.</label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'COPD (Chronic Obstructive Pulmonary Disease)\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_11\' id=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_1\' class=\'fo-right-margin-5\' data-export-label=\'Primary_Dx\' ><label for=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_1\'>COPD (Chronic Obstructive Pulmonary Disease)</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'CHF (Congestive Heart Failure)\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_11\' id=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_2\' class=\'fo-right-margin-5\' data-export-label=\'Primary_Dx\' ><label for=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_2\'>CHF (Congestive Heart Failure)</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'CAD (Coronary Artery Disease)\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_11\' id=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_3\' class=\'fo-right-margin-5\' data-export-label=\'Primary_Dx\' ><label for=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_3\'>CAD (Coronary Artery Disease)</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'CKD (Chronic Kidney Disease)\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_11\' id=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_4\' class=\'fo-right-margin-5\' data-export-label=\'Primary_Dx\' ><label for=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_4\'>CKD (Chronic Kidney Disease)</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Diabetes\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_11\' id=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_5\' class=\'fo-right-margin-5\' data-export-label=\'Primary_Dx\' ><label for=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_5\'>Diabetes</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'None of the above.\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_11\' id=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_6\' class=\'fo-right-margin-5\' data-export-label=\'Primary_Dx\' ><label for=\'FormField11_6a3afb1a-4285-453b-bbfa-cce939109205_6\'>None of the above.</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Do you have a specific health goal you would like to work on?</label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes - I have one specific health goal I would like to work on\'  name=\'checkbox12\' id=\'FormField12_6a3afb1a-4285-453b-bbfa-cce939109205_1\' class=\'right\' data-export-label=\'Goal\' ><label for=\'FormField12_6a3afb1a-4285-453b-bbfa-cce939109205_1\'>Yes - I have one specific health goal I would like to work on</label></div><div class=\'flow\'><input type=\'radio\' value=\'Yes - There are many health goals that I would like to work on\'  name=\'checkbox12\' id=\'FormField12_6a3afb1a-4285-453b-bbfa-cce939109205_2\' class=\'right\' data-export-label=\'Goal\' ><label for=\'FormField12_6a3afb1a-4285-453b-bbfa-cce939109205_2\'>Yes - There are many health goals that I would like to work on</label></div><div class=\'flow\'><input type=\'radio\' value=\'No - I would like help determining what my health goal should be\'  name=\'checkbox12\' id=\'FormField12_6a3afb1a-4285-453b-bbfa-cce939109205_3\' class=\'right\' data-export-label=\'Goal\' ><label for=\'FormField12_6a3afb1a-4285-453b-bbfa-cce939109205_3\'>No - I would like help determining what my health goal should be</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Does your health goal fit under any of the below categories? If not, that&#39;s okay! Select all that apply.</label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Improve quality of life\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_1\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_1\'>Improve quality of life</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Improve physical health\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_2\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_2\'>Improve physical health</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Improve mental health\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_3\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_3\'>Improve mental health</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Improve nutrition\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_4\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_4\'>Improve nutrition</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Improve management of a chronic health condition\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_5\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_5\'>Improve management of a chronic health condition</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Improve coordination of care\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_6\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_6\'>Improve coordination of care</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Weight loss\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_7\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_7\'>Weight loss</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Reduce A1C or other diabetic symptoms\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_8\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_8\'>Reduce A1C or other diabetic symptoms</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Connect to local resource and support services\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_9\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_9\'>Connect to local resource and support services</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'My goal does not fit into any of these categories.\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_13\' id=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_10\' class=\'fo-right-margin-5\' data-export-label=\'Health_Goal\' ><label for=\'FormField13_6a3afb1a-4285-453b-bbfa-cce939109205_10\'>My goal does not fit into any of these categories.</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Community Health Workers (CHWs) can meet individuals in the home, practice, community, via Zoom, or via phone. Do you have a communication preference? Select all that apply.</label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'In Home\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_14\' id=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_1\' class=\'fo-right-margin-5\' data-export-label=\'Communication_Preference\' ><label for=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_1\'>In Home</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Community\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_14\' id=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_2\' class=\'fo-right-margin-5\' data-export-label=\'Communication_Preference\' ><label for=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_2\'>Community</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Phone\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_14\' id=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_3\' class=\'fo-right-margin-5\' data-export-label=\'Communication_Preference\' ><label for=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_3\'>Phone</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Zoom\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_14\' id=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_4\' class=\'fo-right-margin-5\' data-export-label=\'Communication_Preference\' ><label for=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_4\'>Zoom</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Primary Care Practice\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_14\' id=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_5\' class=\'fo-right-margin-5\' data-export-label=\'Communication_Preference\' ><label for=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_5\'>Primary Care Practice</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'CHW Office\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_14\' id=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_6\' class=\'fo-right-margin-5\' data-export-label=\'Communication_Preference\' ><label for=\'FormField14_6a3afb1a-4285-453b-bbfa-cce939109205_6\'>CHW Office</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Are there any barriers preventing you from reaching your health goal? Select all that apply.</label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Transportation\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_1\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_1\'>Transportation</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Financial Strain\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_2\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_2\'>Financial Strain</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Housing\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_3\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_3\'>Housing</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Complex Health Status\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_4\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_4\'>Complex Health Status</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Mental Health Status\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_5\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_5\'>Mental Health Status</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Knowledge/Awareness\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_6\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_6\'>Knowledge/Awareness</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Motivation\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_7\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_7\'>Motivation</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Isolation\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_8\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_8\'>Isolation</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Pain\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_9\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_9\'>Pain</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Limited Mobility\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_10\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_10\'>Limited Mobility</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Medication Management/Medical Equipment\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_11\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_11\'>Medication Management/Medical Equipment</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Childcare/Caregiver Needs\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_12\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_12\'>Childcare/Caregiver Needs</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Dental Issues\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_13\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_13\'>Dental Issues</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Substance Use\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_14\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_14\'>Substance Use</label></div><div class=\'separate Chkbx\'><input type=\'checkbox\' value=\'Access to Internet\'  name=\'c0263cef-465f-4636-b065-af078bd6f495_FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_checkbox_15\' id=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_15\' class=\'fo-right-margin-5\' data-export-label=\'Barriers\' ><label for=\'FormField15_6a3afb1a-4285-453b-bbfa-cce939109205_15\'>Access to Internet</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField16_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'control-label  \'>Thank you for your submission. Someone will reach out to the referred individual to follow-up on this referral.                                                   Please include any additional information that may be relevant to this referral.</label><div>\
<textarea rows=\'10\' name=\'FormField16_6a3afb1a-4285-453b-bbfa-cce939109205\' id=\'FormField16_6a3afb1a-4285-453b-bbfa-cce939109205\' class=\'form-control textarea-medium\'   data-export-label=\'Additional_Comments\'  placeholder=\'\'></textarea>\
</div></div>\
\
<div id=\'form-errors\' class=\'alert alert-danger fade in\' role=\'alert\' style=\'display:none\'></div>\
<div class=\'form-group ignore\'><div class=\'form-group ButtonHolder\'><div class=\'col-sm-4 col-sm-offset-2\'><button id=\'fb-submitButton\' type=\'button\' class=\'btn btn-primary Button\' value=\'Submit\'>Submit</button></div></div></div>\
</div>";

fbConfigScript.innerHTML = "window.formHost = 'https://formulate.geonetric.com'; window.submissionHost = 'https://formulate.geonetric.com/';";
fbRenderedScripts.innerHTML = renderedScripts.replace(/<script>/ig, '\n').replace(/<\/script>/ig, '').replace(/\s{4}/ig, "");
fbRenderedIntegrations.innerHTML = "";
fbRenderedCssContainer.innerHTML = '';

fbScriptTag.parentNode.insertBefore(fbRenderContainer, fbScriptTag.nextSibling);

fbBodyTag.appendChild(fbConfigScript);
fbBodyTag.appendChild(fbRequireJSScript);
if (fbEnableInstaMedScript === 'True')
    fbHeadTag.appendChild(fbInstaMedJSScript);
fbBodyTag.insertAdjacentHTML('beforeend', fbEmbeddedCss);
fbBodyTag.appendChild(fbGeoCaptchaCallback);
fbBodyTag.appendChild(fbRenderedIntegrations);
fbBodyTag.appendChild(fbRenderedCssContainer);
fbBodyTag.appendChild(fbRenderedScripts);


fbScriptTag.parentNode.removeChild(fbScriptTag);