www.calassist.org
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urlscan Pro
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Submitted URL: http://calassist.org/
Effective URL: https://www.calassist.org/
Submission: On June 11 via manual from US — Scanned from DE
Effective URL: https://www.calassist.org/
Submission: On June 11 via manual from US — Scanned from DE
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<h2>Get matched to life-changing benefits</h2>
<h4><br></h4>
<h4>Available through your Health Plan and Community Partners.</h4>
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<div class="label">Nutritious Meals & Groceries</div>
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<div class="label">Independent Living Support</div>
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<path d="M12.25,18a.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<path d="M12.5,18.25a.25.25,0,0,1-.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<path d="M12.75,18a.25.25,0,0,1-.25.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<line x1="9.5" y1="22" x2="14.5" y2="22" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
</svg></div>
<div class="text-container text-container-hidden">
<div class="label">Housing & Transition Services</div>
<div class="text">Help find, pay for, and move into a safe home</div>
</div>
</div>
</div>
<div>
<div id="id-37dcbdf4" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24">
<defs></defs>
<title>hospital-house</title>
<path d="M16.5,13a.5.5,0,0,0-.5-.5H13.5V10a.5.5,0,0,0-.5-.5H11a.5.5,0,0,0-.5.5v2.5H8a.5.5,0,0,0-.5.5v2a.5.5,0,0,0,.5.5h2.5V18a.5.5,0,0,0,.5.5h2a.5.5,0,0,0,.5-.5V15.5H16a.5.5,0,0,0,.5-.5Z"
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<path d="M3.5,11.5v11a1,1,0,0,0,1,1h15a1,1,0,0,0,1-1v-11" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
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</svg></div>
<div class="text-container text-container-hidden">
<div class="label">Short-Term Recovery Services</div>
<div class="text">Get back up on your feet after an illness</div>
</div>
</div>
</div>
<div>
<div id="id-e644f6c2" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24">
<defs></defs>
<title>phone-chatting</title>
<path d="M4.5,3.75A.25.25,0,1,1,4.25,4a.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
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<path d="M8.5,3.75A.25.25,0,1,1,8.25,4a.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<path d="M10.5,3.75a.25.25,0,1,1-.25.25.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<path d="M15.5,12.75a.25.25,0,1,1-.25.25.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<path d="M17.5,12.75a.25.25,0,1,1-.25.25.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<path d="M19.5,12.75a.25.25,0,1,1-.25.25.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
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<path d="M13.5,3.5h3a2,2,0,0,1,2,2v4" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
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<path d="M13,21.25h0a.25.25,0,0,1,.25.25h0a.25.25,0,0,1-.25.25h0a.25.25,0,0,1-.25-.25h0a.25.25,0,0,1,.25-.25" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
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</svg></div>
<div class="text-container text-container-hidden">
<div class="label">Unlimited Talk & Text</div>
<div class="text">Get a free smartphone and data plan</div>
</div>
</div>
</div>
<div>
<div id="option-xb6qW7FxZWkkUn36LonKR" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24">
<defs></defs>
<title>add-circle</title>
<circle cx="12" cy="12" r="11" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></circle>
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<line x1="18" y1="12" x2="6" y2="12" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
</svg></div>
<div class="text-container text-container-hidden">
<div class="label">And more...</div>
<div class="text">Counseling services, CalFresh enrollment, etc.</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="input-94f0bca3-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="input-94f0bca3">Device</label>
<div class="input">
<div style="display:flex;">
<div style="flex:1;position:relative;"><input id="input-94f0bca3" data-type="input" data-label="Device" data-variable="Device" data-mask="" name="input-94f0bca3" placeholder="Placeholder" pattern="" maxlength="" data-trim=""
autofocus="" autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>Device</span></div>
</div>
</div><datalist id="datalist-input-94f0bca3">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="input-9183192a-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="input-9183192a">Referred by</label>
<div class="input">
<div style="display:flex;">
<div style="flex:1;position:relative;"><input id="input-9183192a" data-type="input" data-label="referred_by" data-variable="ref" data-mask="" name="input-9183192a" placeholder="Placeholder" pattern="" maxlength="" data-trim=""
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<div class="input-floating-label"><span>Referred by</span></div>
</div>
</div><datalist id="datalist-input-9183192a">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-d646d569">
<div style="padding-top:15px; padding-bottom:16px;"><button id="id-d646d569" class="generic-button continue medium"
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<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
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<div class="success"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
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<div class="error"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
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</svg></div>
</div>
<div class="content align-center">
<div class="label-container"><span class="label">Get matched (Less than 2 min)</span></div><span class="graphic"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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</svg></span>
</div>
</button></div>
</div>
</div>
</section>
<section id="id-ccfb926e" name="start-dr" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block show_all" style="" data-blocktype="text-image-content">
<div class="block-content text-image-content-block inner-mid" id="text-image-content-block-text-image-content-517d7a24">
<div style="padding-top:20px; padding-bottom:20px; padding-left:20px;">
<div class="text-image-content-body" style="align-items:center;; row-gap: 21px; column-gap: 32px;">
<div class="text-image-content-image" style="width: calc((100% - 32px) * 6 / 12);"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/1c3f1d41-44fe-4acc-a0d9-34544ec803cd.png" style="border-radius:30px;"
alt="Default"></div>
<div class="text-image-content-text rich-text" style="width: calc((100% - 32px) * (12 - 6) / 12);">
<h3>See if your qualify for</h3>
<h1><strong>12 weeks of free healthy food</strong></h1>
<h5><br></h5>
<h4>Delivered to your doorstep.</h4>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_desktop" style="background-color:none;" data-blocktype="rich-text">
<div class="block-content text-block inner-wide align-center" id="text-block-headline-e8890d5e">
<div class="rich-text" style="padding-top:20px;">
<h3>See if you qualify for</h3>
</div>
</div>
</div>
<div class="block hide_desktop" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-rich-text-c58a8adb">
<div class="rich-text" style="padding-bottom:0px;">
<h1>12 weeks of <u>free</u> groceries</h1>
</div>
</div>
</div>
<div class="block hide_desktop" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-rich-text-a7822f24">
<div class="rich-text" style="padding-top:10px; padding-bottom:20px;">
<h4>Delivered to your Doorstep</h4>
</div>
</div>
</div>
<div class="block hide_desktop" style="" data-blocktype="image">
<div class="block-content image-block inner-narrow" style="" id="image-block-img-cedc7c1a">
<div style="text-align:center;padding-top:20px; padding-bottom:20px;"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/de332fb7-247e-4bae-a64a-0a953c3d3fd7.png" style="height:48%;width:48%;" alt="Custom"></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-rich-text-8d59709f">
<div class="rich-text" style="padding-top:0px; padding-bottom:20px;">
<p>Or get matched to one of these other benefits</p>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-list-v2">
<div class="block-content rich-list-v2-block inner-mid" id="rich-list-v2-block-id-46b6a67e" data-is-animated="false" data-animation-timeout="500" data-animation-mode="all" data-action="next"
data-options="{"columnsMobile":1,"withAction":false,"containerClass":"inner-mid","columns":3,"paddingRight":"20","animationMode":"all","animationTimeoutInMs":500,"type":"rich-list-v2","paddingBottom":20,"options":[{"image":"1384c95c-ea21-4e35-803f-ed2f1ee6df73.png","svg":null,"icon":null,"label":"Housing&nbsp;Transition&nbsp;&amp;&nbsp;Navigation&nbsp;Services","id":"id-c47084ad","text":""},{"image":"41973a5b-fa07-45a2-bb2a-d6879b2c6a12.png","svg":null,"icon":null,"text":"","label":"Short-Term&nbsp;Recovery&nbsp;Services","id":"id-d6297079"},{"image":"e4417e37-9174-4456-aa20-599abc6bd792.png","svg":null,"icon":null,"text":"","id":"id-751ab8bc","label":"Caregiver&nbsp;Support"},{"image":"c54a1202-facf-4060-9b6e-4868e2f709af.png","svg":null,"icon":null,"id":"id-10ced1a7","label":"Data&nbsp;Plan&nbsp;with&nbsp;Talk&nbsp;&amp;&nbsp;Text","text":""},{"image":"f30c4e46-2f96-4644-bb30-b2abfbfb0fa9.png","svg":null,"icon":null,"id":"id-dac611d3","text":"","label":"CalFresh&nbsp;Enrollment"},{"image":"2f9438f9-a9db-4394-a7a3-855b06fee157.png","svg":null,"icon":null,"id":"id-7fad2f94","text":"","label":"And&nbsp;more..."}],"name":"rich-list-v2","action":"next","id":"id-46b6a67e","paddingTop":"0","isAnimated":false,"paddingLeft":"25"}">
<div style="padding-top:0px; padding-right:20px; padding-bottom:20px; padding-left:25px;">
<div class="rich-list-v2">
<div class="rich-list-v2-options grid-cols-3 mobile-grid-cols-1">
<div>
<div id="id-c47084ad" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/1384c95c-ea21-4e35-803f-ed2f1ee6df73.png" alt="id-c47084ad"></div>
<div class="text-container text-container-hidden">
<div class="label">Housing Transition & Navigation Services</div>
<div class="text"></div>
</div>
</div>
</div>
<div>
<div id="id-d6297079" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/41973a5b-fa07-45a2-bb2a-d6879b2c6a12.png" alt="id-d6297079"></div>
<div class="text-container text-container-hidden">
<div class="label">Short-Term Recovery Services</div>
<div class="text"></div>
</div>
</div>
</div>
<div>
<div id="id-751ab8bc" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/e4417e37-9174-4456-aa20-599abc6bd792.png" alt="id-751ab8bc"></div>
<div class="text-container text-container-hidden">
<div class="label">Caregiver Support</div>
<div class="text"></div>
</div>
</div>
</div>
<div>
<div id="id-10ced1a7" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c54a1202-facf-4060-9b6e-4868e2f709af.png" alt="id-10ced1a7"></div>
<div class="text-container text-container-hidden">
<div class="label">Data Plan with Talk & Text</div>
<div class="text"></div>
</div>
</div>
</div>
<div>
<div id="id-dac611d3" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/f30c4e46-2f96-4644-bb30-b2abfbfb0fa9.png" alt="id-dac611d3"></div>
<div class="text-container text-container-hidden">
<div class="label">CalFresh Enrollment</div>
<div class="text"></div>
</div>
</div>
</div>
<div>
<div id="id-7fad2f94" class="rich-list-v2-option">
<div class="loader"></div>
<div class="graphics-container graphics-container-hidden"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/2f9438f9-a9db-4394-a7a3-855b06fee157.png" alt="id-7fad2f94"></div>
<div class="text-container text-container-hidden">
<div class="label">And more...</div>
<div class="text"></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
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<p>Provided By</p>
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<div class="label">And more...</div>
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<h2>Who is your health plan provider?</h2>
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<div class="label">I don't see my provider</div>
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<h5><br></h5>
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<h2>Who is your health plan provider?</h2>
<p>Enter your provider</p>
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<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
</div>
<div class="content align-center">
<div class="label-container"><span class="label">Next</span></div><span class="graphic"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="40" y1="128" x2="216" y2="128" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<polyline points="144 56 216 128 144 200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span>
</div>
</button></div>
</div>
</div>
</section>
<section id="id-b8be4be0" name="chronic-condition" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-40b90fc8">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-ebed437d">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Do you have any of these chronic diseases?</h2>
<h3><br></h3>
<h3>Select all that apply, then click next</h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-e3c422ac" data-align-siblings="true" data-multiselect="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="option-WIx6pJHCRPSHzrkd0wyXZ" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-WIx6pJHCRPSHzrkd0wyXZ" data-conditional="true" data-answer="Alcohol Use" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/6638dd26-2bbe-4dc6-b571-0b466e7cc524" alt="option-WIx6pJHCRPSHzrkd0wyXZ"></div>
<div class="label-container">
<div class="label">Alcohol Use</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="id-e77e9a9b" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable="" value="id-e77e9a9b"
data-conditional="true" data-answer="Arthritis" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/2ba7fb6d-2380-4d9a-bb5d-c212da7d7964" alt="id-e77e9a9b"></div>
<div class="label-container">
<div class="label">Arthritis</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-4d4cd6c2" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="id-6f8d794d" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable="" value="id-6f8d794d"
data-conditional="true" data-answer="Asthma" data-destination="id-4d4cd6c2" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/0308f7fd-0bba-43ce-bbe8-12533c4fab1c" alt="id-6f8d794d"></div>
<div class="label-container">
<div class="label">Asthma</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">4</div><input type="checkbox" id="id-89b50830" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable="" value="id-89b50830"
data-conditional="true" data-answer="Atrial Fibrillation" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/09d3d299-a2e6-4205-a695-3cf302fd5e32" alt="id-89b50830"></div>
<div class="label-container">
<div class="label">Atrial Fibrillation</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">5</div><input type="checkbox" id="option-bGM3FZIfTH8Qz5VKDd1wn" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-bGM3FZIfTH8Qz5VKDd1wn" data-conditional="true" data-answer="Behavioral or Mental Health Issues" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/5ad78daa-053a-4d06-9cff-1a6d99297c13.png" alt="option-bGM3FZIfTH8Qz5VKDd1wn"></div>
<div class="label-container">
<div class="label">Behavioral Health or Mental Health Issues</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">6</div><input type="checkbox" id="option-PXoUDAzgpMBzxSNAOBxiB" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-PXoUDAzgpMBzxSNAOBxiB" data-conditional="true" data-answer="Cancer" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/70745d58-e730-47b1-9d58-d05333f80622.png" alt="option-PXoUDAzgpMBzxSNAOBxiB"></div>
<div class="label-container">
<div class="label">Cancer</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">7</div><input type="checkbox" id="option--pLGs5Jp3hWJ5lSip-LQu" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option--pLGs5Jp3hWJ5lSip-LQu" data-conditional="true" data-answer="COPD" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/23444c97-bbc1-4fa7-a2db-2f4536a384fe" alt="option--pLGs5Jp3hWJ5lSip-LQu"></div>
<div class="label-container">
<div class="label">COPD</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">8</div><input type="checkbox" id="option-RzIYCUuib4taWanxI0e5v" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-RzIYCUuib4taWanxI0e5v" data-conditional="true" data-answer="Depression" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/d4752cef-4c04-4855-9552-8c437547fd62" alt="option-RzIYCUuib4taWanxI0e5v"></div>
<div class="label-container">
<div class="label">Depression</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">9</div><input type="checkbox" id="option-jL7Pr8RyLSHSlPYJvYELB" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-jL7Pr8RyLSHSlPYJvYELB" data-conditional="true" data-answer="Diabetes" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/e29d5a57-5ba0-45cf-864f-3f3fa35a095b.png" alt="option-jL7Pr8RyLSHSlPYJvYELB"></div>
<div class="label-container">
<div class="label">Diabetes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">10</div><input type="checkbox" id="option-psaSiMqIvTpa_BCJvwt5k" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-psaSiMqIvTpa_BCJvwt5k" data-conditional="true" data-answer="Heart Disease" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c3412685-3881-4b64-8ad7-4a56bfe3cafc.png" alt="option-psaSiMqIvTpa_BCJvwt5k"></div>
<div class="label-container">
<div class="label">Heart Disease</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">11</div><input type="checkbox" id="option-ciNSr1ffZGHi6TLALf1Mb" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-ciNSr1ffZGHi6TLALf1Mb" data-conditional="true" data-answer="Hepatitis" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/23f9e6c5-ba65-41f3-bc3c-751b32deb4f7" alt="option-ciNSr1ffZGHi6TLALf1Mb"></div>
<div class="label-container">
<div class="label">Hepatitis</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">12</div><input type="checkbox" id="option-vVpU6rU5t70tNhir0j45A" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-vVpU6rU5t70tNhir0j45A" data-conditional="true" data-answer="High Cholesterol" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/9b773f7c-d09e-4cef-92c5-689f293a8bf1.png" alt="option-vVpU6rU5t70tNhir0j45A"></div>
<div class="label-container">
<div class="label">High Cholesterol</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">13</div><input type="checkbox" id="option-tR_x6kN25NBGW2mQ4tqQH" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-tR_x6kN25NBGW2mQ4tqQH" data-conditional="true" data-answer="HIV/AIDS" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/bd5873f7-2674-4dad-b948-aa32445b72db" alt="option-tR_x6kN25NBGW2mQ4tqQH"></div>
<div class="label-container">
<div class="label">HIV/AIDS</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">14</div><input type="checkbox" id="option-Yo12vuz6dpfoBCmONz5wt" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-Yo12vuz6dpfoBCmONz5wt" data-conditional="true" data-answer="High Blood Pressure" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/cb4d8291-9955-40e9-8068-2f088c07b934.png" alt="option-Yo12vuz6dpfoBCmONz5wt"></div>
<div class="label-container">
<div class="label">High Blood Pressure</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">15</div><input type="checkbox" id="option-f85Jz78OR2Y1DDyr93mK6" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-f85Jz78OR2Y1DDyr93mK6" data-conditional="true" data-answer="High BMI (e.g. Overweight)" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c390ecf4-4dc3-4851-91e5-4638f45982c1.png" alt="option-f85Jz78OR2Y1DDyr93mK6"></div>
<div class="label-container">
<div class="label">High BMI (e.g. Overweight)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8fb21328" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">16</div><input type="checkbox" id="option-l6TYuNPYZTwoh5ixjFx6P" data-tracking="false" data-event-name="" data-type="multiple-choice" data-label="chronic_condition" name="id-e3c422ac" data-variable=""
value="option-l6TYuNPYZTwoh5ixjFx6P" data-conditional="true" data-answer="Kidney Disease" data-destination="id-8fb21328" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
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<div class="label">Kidney Disease</div>
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<div></div>
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<div class="label">Maternal Health</div>
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</div>
<div></div>
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<div class="block-content text-block align-center inner-mid" id="text-block-id-2135dbf7">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Do you have a hard time controlling your asthma?</h2>
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<div class="label">No</div>
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</div>
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<h2>What other chronic diseases do you have?</h2>
<p>Type in your diseases</p>
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<div class="block" style="" data-blocktype="textarea">
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<section id="id-8fb21328" name="discharge" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
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<h2>Have you recently left any of these facilities?</h2>
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<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb4021b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb4021b4');" type="checkbox" id="id-2a3a995b" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="discharged_from" name="id-c5cf0e0e" data-variable="" value="id-2a3a995b" data-conditional="true" data-answer="Nursing Facility" data-destination="id-eb4021b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c6adfaa5-db78-44ce-a9cf-581a5c73cf1d" alt="id-2a3a995b"></div>
<div class="label-container">
<div class="label">Nursing Facility</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb4021b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">3</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb4021b4');" type="checkbox" id="id-841c7ab8" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="discharged_from" name="id-c5cf0e0e" data-variable="" value="id-841c7ab8" data-conditional="true" data-answer="Recuperative Care Center" data-destination="id-eb4021b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/32c34373-0c9d-438b-8278-f027d29ee7b4" alt="id-841c7ab8"></div>
<div class="label-container">
<div class="label">Recuperative Care Center</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb4021b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">4</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb4021b4');" type="checkbox" id="id-b580c4cf" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="discharged_from" name="id-c5cf0e0e" data-variable="" value="id-b580c4cf" data-conditional="true" data-answer="Substance Abuse Treatment Center" data-destination="id-eb4021b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/1fc1ddbd-5340-4ea9-ab6b-95a5a6912dea" alt="id-b580c4cf"></div>
<div class="label-container">
<div class="label">Substance Abuse Treatment Center</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb4021b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">5</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb4021b4');" type="checkbox" id="id-91e4dfab" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="discharged_from" name="id-c5cf0e0e" data-variable="" value="id-91e4dfab" data-conditional="true" data-answer="Correctional Facility" data-destination="id-eb4021b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/708dd74c-ff22-4f90-9ce1-6105b139b818" alt="id-91e4dfab"></div>
<div class="label-container">
<div class="label">Correctional Facility</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb4021b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">6</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb4021b4');" type="checkbox" id="id-7197f632" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="discharged_from" name="id-c5cf0e0e" data-variable="" value="id-7197f632" data-conditional="true" data-answer="Mental Health Treatment Center" data-destination="id-eb4021b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/f46c7234-a484-49b5-81a8-fae8b365829e" alt="id-7197f632"></div>
<div class="label-container">
<div class="label">Mental Health Treatment Center</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-f5c8653e" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb4021b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb4021b4');" type="radio" id="id-9f376cb4" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="discharged_from" name="id-f5c8653e" data-variable="" value="id-9f376cb4" data-conditional="true" data-answer="None of these apply to me" data-destination="id-eb4021b4" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">None of these apply to me</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-eb4021b4" name="risk-of-going-in" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-530841b4">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-f8ec9b65">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you at risk of entering into either of these facilities?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-753a35ee" data-align-siblings="true" data-multiselect="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-b0fe11c7" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-b0fe11c7');" type="checkbox" id="id-dc35898e" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="risk_of_healthcare_facility" name="id-753a35ee" data-variable="" value="id-dc35898e" data-conditional="true" data-answer="Hospital" data-destination="id-b0fe11c7" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/9f602c86-6fed-4eae-8d66-c2bdb33e8e9b" alt="id-dc35898e"></div>
<div class="label-container">
<div class="label">Hospital</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-b0fe11c7" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-b0fe11c7');" type="checkbox" id="id-29e91e21" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="risk_of_healthcare_facility" name="id-753a35ee" data-variable="" value="id-29e91e21" data-conditional="true" data-answer="Nursing Facility" data-destination="id-b0fe11c7" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c6adfaa5-db78-44ce-a9cf-581a5c73cf1d" alt="id-29e91e21"></div>
<div class="label-container">
<div class="label">Nursing Facility</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-ec410fec" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-b0fe11c7" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-b0fe11c7');" type="radio" id="id-2068cc3a" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="risk_of_healthcare_facility" name="id-ec410fec" data-variable="" value="id-2068cc3a" data-conditional="true" data-answer="I don't think so" data-destination="id-b0fe11c7" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">I don't think so</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-b0fe11c7" name="current-facility" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-39f444b0">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-d04fa83f">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you facing either of these situations?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-fe8a053b" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-8190661c" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-8190661c');" type="radio" id="id-296d495a" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="current_healthcare_facility" name="id-fe8a053b" data-variable="" value="id-296d495a" data-conditional="true" data-answer="I Live in a Nursing Facility" data-destination="id-8190661c" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/88bd7def-336e-47fc-bf97-59619955bcfb" alt="id-296d495a"></div>
<div class="label-container">
<div class="label">I Live in a Nursing Facility</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-20a3826e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-20a3826e');" type="radio" id="id-1b75270d" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="current_healthcare_facility" name="id-fe8a053b" data-variable="" value="id-1b75270d" data-conditional="true" data-answer="I Live at Home and I Need Help Caring for Myself" data-destination="id-20a3826e"
data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/8a7e56c0-a0f2-4fa8-a49b-4a656ab71fd8" alt="id-1b75270d"></div>
<div class="label-container">
<div class="label">I Live at Home and I Need Help Caring for Myself</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-e65216ec" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-e696667d" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','screen-e696667d');" type="radio" id="id-a0611d44" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="current_healthcare_facility" name="id-e65216ec" data-variable="" value="id-a0611d44" data-conditional="true" data-answer="Neither of these apply to me" data-destination="screen-e696667d" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Neither of these apply to me</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-8190661c" name="live-nursing-home" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-9d9f1750">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-b6d72edd">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you receiving medically necessary care in this nursing facility?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-afc52fd5" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-64312551" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-64312551');" type="radio" id="id-e28639f9" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="nursing_facility" name="id-afc52fd5" data-variable="" value="id-e28639f9" data-conditional="true" data-answer="Yes" data-destination="id-64312551" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/26c9a6ec-3994-4654-8bf3-57b75e446354" alt="id-e28639f9"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-e696667d" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','screen-e696667d');" type="radio" id="id-4bf9c18d" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="nursing_facility" name="id-afc52fd5" data-variable="" value="id-4bf9c18d" data-conditional="true" data-answer="No" data-destination="screen-e696667d" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/87653081-e53a-458d-b8cb-47b5b3da06d1" alt="id-4bf9c18d"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-64312551" name="live-nursing-more-60" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-e428a058">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-58733c9c">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Have you lived there for more than 60 days?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-f1dbd48f" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-3dc1897c" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-3dc1897c');" type="radio" id="id-b680cc60" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="nursing_more_than_sixty_days" name="id-f1dbd48f" data-variable="" value="id-b680cc60" data-conditional="true" data-answer="Yes" data-destination="id-3dc1897c" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/75fe8ab7-3d7e-4fa4-b60b-69f531840162" alt="id-b680cc60"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-3dc1897c" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-3dc1897c');" type="radio" id="id-2fde39e7" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="nursing_more_than_sixty_days" name="id-f1dbd48f" data-variable="" value="id-2fde39e7" data-conditional="true" data-answer="No" data-destination="id-3dc1897c" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c9c565af-0333-498b-bf7c-610131582047" alt="id-2fde39e7"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-3dc1897c" name="moving-back-into-community" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-1b1d7d29">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-fdccf58e">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Would you like to move out of your nursing facility and still receive medically necessary care?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-db7141f1" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-e696667d" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','screen-e696667d');" type="radio" id="id-63bb15b7" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="move_back_into_community" name="id-db7141f1" data-variable="" value="id-63bb15b7" data-conditional="true" data-answer="Yes" data-destination="screen-e696667d" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/3f5c0803-53d5-4ff6-b084-73ca163650b4" alt="id-63bb15b7"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb91c22e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb91c22e');" type="radio" id="id-cac25a83" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="move_back_into_community" name="id-db7141f1" data-variable="" value="id-cac25a83" data-conditional="true" data-answer="No" data-destination="id-eb91c22e" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/69267495-cdb5-4d8e-925b-a371c2d807cd" alt="id-cac25a83"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-20a3826e" name="impaired-no-support" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-dbf28e89">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-39a2d460">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Do you need assistance caring for yourself but don't have anyone who can help you?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-3f51f1e0" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-fd424f89" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-fd424f89');" type="radio" id="id-f20e03bd" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="impaired_without_support" name="id-3f51f1e0" data-variable="" value="id-f20e03bd" data-conditional="true" data-answer="Yes" data-destination="id-fd424f89" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/cd6dfeaa-f89a-48ab-bf94-f44414599471" alt="id-f20e03bd"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-fd424f89" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-fd424f89');" type="radio" id="id-a8930b28" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="impaired_without_support" name="id-3f51f1e0" data-variable="" value="id-a8930b28" data-conditional="true" data-answer="No" data-destination="id-fd424f89" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/c14e893d-71cd-4333-8a25-2fd8b3e6d0c4" alt="id-a8930b28"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-fd424f89" name="approved-for-supportive-services" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-2ce368bb">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-162d0698">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you approved or pending approval for In-Home Supportive Services?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-a1189fbe" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-94354d44" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-94354d44');" type="radio" id="id-5b9eb4e8" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="in_home_services" name="id-a1189fbe" data-variable="" value="id-5b9eb4e8" data-conditional="true" data-answer="Yes" data-destination="id-94354d44" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/e6e4953c-a251-45ca-8f40-04ddb49a4277" alt="id-5b9eb4e8"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-94354d44" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-94354d44');" type="radio" id="id-48415ced" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="in_home_services" name="id-a1189fbe" data-variable="" value="id-48415ced" data-conditional="true" data-answer="No" data-destination="id-94354d44" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/0ee7a57c-37ca-48e6-8dbd-3bfbc58508d5" alt="id-48415ced"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-f2b636fe" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-94354d44" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-94354d44');" type="radio" id="id-92c73f9b" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="in_home_services" name="id-f2b636fe" data-variable="" value="id-92c73f9b" data-conditional="true" data-answer="Not sure" data-destination="id-94354d44" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Not sure</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-94354d44" name="caregiver-respite" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-647ae98c">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-2958e9e4">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Do you depend on an unpaid caregiver to support your daily life?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-3838b18e" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-e696667d" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','screen-e696667d');" type="radio" id="id-b40dae9e" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="caregiver_respite" name="id-3838b18e" data-variable="" value="id-b40dae9e" data-conditional="true" data-answer="Yes" data-destination="screen-e696667d" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/b0090b2c-a24a-4040-9f87-a56e83429a32" alt="id-b40dae9e"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-e696667d" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','screen-e696667d');" type="radio" id="id-b5cd3d11" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="caregiver_respite" name="id-3838b18e" data-variable="" value="id-b5cd3d11" data-conditional="true" data-answer="No" data-destination="screen-e696667d" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/77b8e213-0d3c-417c-9de3-eaf0442f41a3" alt="id-b5cd3d11"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="screen-e696667d" name="transition" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="progress-86743932">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-headline-41c5b90b">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you facing any of these situations?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-mc-54b115f2" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-e49b2848" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-e49b2848');" type="radio" id="mco-88776eea" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="transition" name="mc-54b115f2" data-variable="" value="mco-88776eea" data-conditional="true" data-answer="Homeless" data-destination="id-e49b2848" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/558822c5-4657-4137-b88c-c03b665b0c13" alt="mco-88776eea"></div>
<div class="label-container">
<div class="label">I'm Homeless</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-e49b2848" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-e49b2848');" type="radio" id="mco-476f1eba" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="transition" name="mc-54b115f2" data-variable="" value="mco-476f1eba" data-conditional="true" data-answer="Could Become Homeless" data-destination="id-e49b2848" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/30b7c3c3-b2be-4b33-afdb-89dc13d58a72" alt="mco-476f1eba"></div>
<div class="label-container">
<div class="label">I Could Become Homeless</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb91c22e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">3</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb91c22e');" type="radio" id="mco-c04dec93" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="transition" name="mc-54b115f2" data-variable="" value="mco-c04dec93" data-conditional="true" data-answer="Recently Stopped Being Homeless" data-destination="id-eb91c22e" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/04a4f6fd-0079-48d2-a070-77ec147ca80b" alt="mco-c04dec93"></div>
<div class="label-container">
<div class="label">I Recently Stopped Being Homeless</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-mc-418d5efa" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb91c22e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb91c22e');" type="radio" id="mco-65128807" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="transition" name="mc-418d5efa" data-variable="" value="mco-65128807" data-conditional="true" data-answer="None of these apply to me" data-destination="id-eb91c22e" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">None of these apply to me</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-e49b2848" name="housing-transition-services" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-dae8664e">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-79969fe3">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Have you received Housing Transition Navigation Services?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-66549e63" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-f862f4d0" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-f862f4d0');" type="radio" id="id-845bf329" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="house_transition_services" name="id-66549e63" data-variable="" value="id-845bf329" data-conditional="true" data-answer="Yes" data-destination="id-f862f4d0" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/914582d0-334f-4d2e-8987-44d9f419c529" alt="id-845bf329"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-f862f4d0" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-f862f4d0');" type="radio" id="id-dd2ddbf6" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="house_transition_services" name="id-66549e63" data-variable="" value="id-dd2ddbf6" data-conditional="true" data-answer="No" data-destination="id-f862f4d0" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/037ba7a6-8253-4bd1-8aa4-d0ee5a16e525" alt="id-dd2ddbf6"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-93350e62" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-f862f4d0" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-f862f4d0');" type="radio" id="id-8b5c3466" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="house_transition_services" name="id-93350e62" data-variable="" value="id-8b5c3466" data-conditional="true" data-answer="Not sure" data-destination="id-f862f4d0" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Not sure</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-f862f4d0" name="prioritized-housing" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-77055a56">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-214f79ae">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you prioritized for Permanent Supportive Housing or a Rental subsidy?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-42ef9910" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb91c22e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb91c22e');" type="radio" id="id-4dc42bac" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="prioritized_housing" name="id-42ef9910" data-variable="" value="id-4dc42bac" data-conditional="true" data-answer="Yes" data-destination="id-eb91c22e" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/f9535989-3565-4c07-8c42-ceb36d48ed8a" alt="id-4dc42bac"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb91c22e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb91c22e');" type="radio" id="id-8dd54987" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="prioritized_housing" name="id-42ef9910" data-variable="" value="id-8dd54987" data-conditional="true" data-answer="No" data-destination="id-eb91c22e" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/785e76f3-2a93-4ac4-9d4e-1c813c1eb382" alt="id-8dd54987"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-a3eef6a2" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-eb91c22e" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-eb91c22e');" type="radio" id="id-679e25ec" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="prioritized_housing" name="id-a3eef6a2" data-variable="" value="id-679e25ec" data-conditional="true" data-answer="Not sure" data-destination="id-eb91c22e" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Not sure</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-eb91c22e" name="regfrigerator" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-1067b795">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-3ea9dbcc">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Do you have access to a refrigerator?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-28747d99" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-fe0fccc9" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-fe0fccc9');" type="radio" id="id-fcaab9a5" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="refrigerator" name="id-28747d99" data-variable="" value="id-fcaab9a5" data-conditional="true" data-answer="Yes" required="" data-destination="id-fe0fccc9" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/a7d6c2ce-87a9-4173-82e7-0bd275d153c5" alt="id-fcaab9a5"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-87b15f2b" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-87b15f2b');" type="radio" id="id-d40cb365" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="refrigerator" name="id-28747d99" data-variable="" value="id-d40cb365" data-conditional="true" data-answer="No" required="" data-destination="id-87b15f2b" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/8c62c0db-5483-4cd6-a478-f7b591e40b6f" alt="id-d40cb365"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-fe0fccc9" name="food-delivered" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-ee6598ca">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-e75b7e31">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you getting food delivered to your home through a community program?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-1586e439" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-87b15f2b" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-87b15f2b');" type="radio" id="id-33f556d8" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="food_delivery" name="id-1586e439" data-variable="" value="id-33f556d8" data-conditional="true" data-answer="Yes" required="" data-destination="id-87b15f2b" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/8d14da4d-e5fd-45cb-b92a-66dafbcaefaa" alt="id-33f556d8"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-2b0575b5" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-2b0575b5');" type="radio" id="id-c4b9ab4d" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="food_delivery" name="id-1586e439" data-variable="" value="id-c4b9ab4d" data-conditional="true" data-answer="No" required="" data-destination="id-2b0575b5" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/60992ad3-dfc2-481a-9086-1a4709e134c2" alt="id-c4b9ab4d"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-2b0575b5" name="special-diet" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-3f00e59e">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-17a8fbb8">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you on a special diet?</h2>
<h4><br></h4>
<h4>Such as vegetarian, kosher, or gluten-free</h4>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-e706aab4" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:50px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-87b15f2b" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-87b15f2b');" type="radio" id="id-ab4f1e28" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="dietary_restrictions" name="id-e706aab4" data-variable="" value="id-ab4f1e28" data-conditional="true" data-answer="Yes" data-destination="id-87b15f2b" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/21003c4d-f83f-43f0-b98d-ab55e06dad1c" alt="id-ab4f1e28"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-87b15f2b" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-87b15f2b');" type="radio" id="id-bc3a8d82" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="dietary_restrictions" name="id-e706aab4" data-variable="" value="id-bc3a8d82" data-conditional="true" data-answer="No" data-destination="id-87b15f2b" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/58e01e18-ee43-4361-aafc-b464d778db0f" alt="id-bc3a8d82"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-87b15f2b" name="snap" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-1606e981">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-85b05a6e">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you on CalFresh?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="image">
<div class="block-content image-block inner-narrow" style="" id="image-block-img-6ea4c1fc">
<div style="text-align:center;"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/259722b2-5e06-4a96-a81a-51d780fa97b5.png" style="height:45%;width:45%;" alt="Custom"></div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-94504bf7" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-0907320b" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="snap_beneficiary" name="id-94504bf7" data-variable="" value="id-0907320b" data-conditional="true" data-answer="Yes" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/ba017def-14d5-4871-ba03-c4ed8690580e" alt="id-0907320b"></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-ebfb86fc" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-ebfb86fc');" type="radio" id="id-02a15928" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="snap_beneficiary" name="id-94504bf7" data-variable="" value="id-02a15928" data-conditional="true" data-answer="No" data-destination="id-ebfb86fc" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/8c998ed9-5a70-439f-b305-377df6ab7d0e" alt="id-02a15928"></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-mc-c3eafdfe" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-ebfb86fc" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-ebfb86fc');" type="radio" id="mco-73d40f47" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="snap_beneficiary" name="mc-c3eafdfe" data-variable="" value="mco-73d40f47" data-conditional="true" data-answer="Not sure" data-destination="id-ebfb86fc" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Not sure</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-ebfb86fc" name="programs" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-bbb5744f">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-334ececc">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you enrolled in any of the following programs?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-f4e86dd2" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px; padding-left:0px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-509ca1c3" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-f4e86dd2" data-variable="" value="id-509ca1c3" data-conditional="true" data-answer="Section 8 Federal Public Housing Assistance (FPHA)" data-destination="id-544422b4"
data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/70d9fef5-a713-4504-82d6-ae2fd5e574dd" alt="id-509ca1c3"></div>
<div class="label-container">
<div class="label">Section 8 Federal Public Housing Assistance (FPHA)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-e6447634" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-f4e86dd2" data-variable="" value="id-e6447634" data-conditional="true" data-answer="Supplemental Security Income (SSI)" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/37254d47-40e6-419c-88a5-1c6cc0768122" alt="id-e6447634"></div>
<div class="label-container">
<div class="label">Supplemental Security Income (SSI)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">3</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-2d4a7382" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-f4e86dd2" data-variable="" value="id-2d4a7382" data-conditional="true" data-answer="National School Lunch Program's Free Lunch" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/0323c29d-88f9-4b18-bee7-a9462fc1d142" alt="id-2d4a7382"></div>
<div class="label-container">
<div class="label">National School Lunch Program's Free Lunch</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">4</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-631222a8" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-f4e86dd2" data-variable="" value="id-631222a8" data-conditional="true" data-answer="The Veterans Pension or Survivors Pension" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/a33806e6-5835-4d31-9c2e-64c760f4e25a" alt="id-631222a8"></div>
<div class="label-container">
<div class="label">The Veterans Pension or Survivors Pension</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">5</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-b3848156" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-f4e86dd2" data-variable="" value="id-b3848156" data-conditional="true" data-answer="Low Income Home Energy Assistance Plan (LIHEAP)" data-destination="id-544422b4"
data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/221b2e15-c669-4741-890e-deaf4fabdc56" alt="id-b3848156"></div>
<div class="label-container">
<div class="label">Low Income Home Energy Assistance Plan (LIHEAP)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">6</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-f2ae2ceb" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-f4e86dd2" data-variable="" value="id-f2ae2ceb" data-conditional="true" data-answer="Temporary Assistance for Needy Families (TANF)" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/f2781be6-2add-42f0-917f-46212c1f46c6" alt="id-f2ae2ceb"></div>
<div class="label-container">
<div class="label">Temporary Assistance for Needy Families (TANF)</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-56af8ba9" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-101f7bc8" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-101f7bc8');" type="radio" id="id-38b10343" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="id-56af8ba9" data-sensitive="true" name="id-56af8ba9" data-variable="" value="id-38b10343" data-conditional="true" data-answer="None of these" data-destination="id-101f7bc8" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">None of these</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-101f7bc8" name="programs-2" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-5682409d">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-615148a5">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you enrolled in any of the following programs?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-9eb1945a" data-align-siblings="true">
<div style="padding-top:20px; padding-bottom:20px; padding-left:0px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-e4875f1d" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-e4875f1d" data-conditional="true" data-answer="Tribally-Administered Temporary Assistance for Needy Families (TTANF)"
data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/f07fb668-359d-4062-93d1-2e1b2de5c082" alt="id-e4875f1d"></div>
<div class="label-container">
<div class="label">Tribally-Administered Temporary Assistance for Needy Families (TTANF)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-bd40044e" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-bd40044e" data-conditional="true" data-answer="Bureau of Indian Affairs General Assistance" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/e3224444-5d75-4b5a-a85a-8d48a454e90f" alt="id-bd40044e"></div>
<div class="label-container">
<div class="label">Bureau of Indian Affairs General Assistance</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">3</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-edbb2b38" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-edbb2b38" data-conditional="true" data-answer="Food Distribution Program on Indian Reservations (FDPIR)" data-destination="id-544422b4"
data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/5becc68b-c5cb-483f-b446-2bf9a5b3c3e0" alt="id-edbb2b38"></div>
<div class="label-container">
<div class="label">Food Distribution Program on Indian Reservations (FDPIR)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">4</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-36e72015" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-36e72015" data-conditional="true" data-answer="Women, Infants, and Children Program (WIC)" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/f6777d42-8786-42b8-85b5-c9287ff65abf" alt="id-36e72015"></div>
<div class="label-container">
<div class="label">Women, Infants, and Children Program (WIC)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">5</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-a7186201" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-a7186201" data-conditional="true" data-answer="California Work Opportunity and Responsibility to Kids (CalWORKs)" data-destination="id-544422b4"
data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/6e8a59a9-7041-4575-9627-15a58475788b" alt="id-a7186201"></div>
<div class="label-container">
<div class="label">California Work Opportunity and Responsibility to Kids (CalWORKs)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">6</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-4d67be73" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-4d67be73" data-conditional="true" data-answer="Head Start Income Eligible (Tribal Only)" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/e86b7a4e-34d5-4727-b846-040a9ef4574a" alt="id-4d67be73"></div>
<div class="label-container">
<div class="label">Head Start Income Eligible (Tribal Only)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">7</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-7cef9d33" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-9eb1945a" data-variable="" value="id-7cef9d33" data-conditional="true" data-answer="
Greater Avenues for Independence (GAIN)" data-destination="id-544422b4" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/d4e40809-b216-4cda-a6c9-e91667df6ca4" alt="id-7cef9d33"></div>
<div class="label-container">
<div class="label">
Greater Avenues for Independence (GAIN)</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-da071a12" data-align-siblings="">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-544422b4" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['ca-en'].navigation.navigate('go','id-544422b4');" type="radio" id="id-10e254ae" data-tracking="false" data-event-name="" data-type="multiple-choice"
data-label="enrolled_benefit_program" name="id-da071a12" data-variable="" value="id-10e254ae" data-conditional="true" data-answer="None" data-destination="id-544422b4" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">None of these</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-544422b4" name="additional-services" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-16903171">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-56e0d592">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Are you interested in learning more about any of these services</h2>
<p>Select all that apply and press next.</p>
</div>
</div>
</div>
<div class="block show_all" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-d8646e8b" data-align-siblings="true" data-multiselect="">
<div style="padding-top:10px; padding-bottom:20px; padding-left:0px;">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="id-12bc52e7" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="learn_more_services" name="id-d8646e8b" data-variable=""
value="id-12bc52e7" data-conditional="true" data-answer="Case Management" data-destination="id-c3ac4f6a" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/acc4f780-6e06-4e33-9f50-866388be569a" alt="id-12bc52e7"></div>
<div class="label-container">
<div class="label">Case Management</div>
<div class="text">Work with a team of experts to get connected to services</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="id-d86a299a" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="learn_more_services" name="id-d8646e8b" data-variable=""
value="id-d86a299a" data-conditional="true" data-answer="Family Support Services" data-destination="id-c3ac4f6a" data-priority="0">
<div class="option-content picture">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/1f912f9c-11e6-4207-a012-3bbeecfed546" alt="id-d86a299a"></div>
<div class="label-container">
<div class="label">Family Support Services</div>
<div class="text">Crisis intervention & service referrals tailored to families</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="id-6212ef59" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="learn_more_services" name="id-d8646e8b" data-variable=""
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<div class="label">Domestic Violence Support</div>
<div class="text">Educational support on breaking the cycle of violence</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
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<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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<div class="label-container">
<div class="label">LGBTQ+ Resources</div>
<div class="text">Find clinical and social support for the LGBTQ+ Community</div>
</div>
</div>
<div></div>
</label></div>
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<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
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<div class="image-container"><img src="https://storage.googleapis.com/builder.zenflow.de/ca-en/www/assets/548d4e14-ccbb-4adb-bc70-15bf95bc6413" alt="id-8c11fc35"></div>
<div class="label-container">
<div class="label">Emergency Assistance</div>
<div class="text">Get needed support to deal with a crisis and get stable</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
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<div class="label">Information & Referral Services</div>
<div class="text">Get referrals to basic services tailored to your situation</div>
</div>
</div>
<div></div>
</label></div>
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<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-c3ac4f6a" hey-important="" hey-autoredirect="false"><label>
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<div class="label">Parenting Education</div>
<div class="text">Access education on positive parenting techniques</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
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<div class="label">Diaper Assistance Program</div>
<div class="text">Receive free diapers for your newborn or baby</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
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<div class="label">I'm not interested in any of these services</div>
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<section id="id-c3ac4f6a" name="preferred-language" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
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<div class="rich-text" style="padding-top:20px; padding-right:0px; padding-bottom:20px;">
<h2>What language do you prefer to speak in?</h2>
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<div class="label">English</div>
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<div class="label">Spanish</div>
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data-label="preferred_language" name="mc-190d80b3" data-variable="" value="mco-c063611f" data-conditional="true" data-answer="Vietnamese" required="" data-destination="id-d9239924" data-priority="0">
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<div class="label">Vietnamese</div>
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<div class="label">Other</div>
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</div>
</div>
</div>
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<h4><br></h4>
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<h2>What language do you prefer to speak in?</h2>
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</section>
<section id="id-d9239924" name="loader" data-type="user" class="undefined with-avatar" data-header="header">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-4eeb4b6f">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Matching you to benefits 🎉 </h2>
<h4>Just give us a moment</h4>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="loader">
<div style="" class="block-content loader-block center inner-narrow" id="loader-block-id-70e53233" data-id="id-70e53233" data-timeout="4000" data-action="go"
data-options="{"redirectURL":"https://heyflow.app","destination":"id-72149c86","type":"loader","timeout":"4000","target":"_self","paddingBottom":20,"name":"loader","action":"go","disabled":false,"paddingTop":20,"id":"id-70e53233","class":"center&nbsp;inner-narrow"}">
<div style="padding-top:20px; padding-bottom:20px;">
<div id="id-70e53233" class="circle-loader">
<div class="circle-loader-checkmark draw"></div>
</div>
</div>
</div>
</div>
</section>
<section id="id-72149c86" name="success" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-8d52f43b">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-8f4c765a">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h2>Success! We've found one or more free services you could be eligible for.</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="steps">
<div class="block-content steps-block inner-mid" id="steps-block-id-512173dd">
<div style="padding-top:20px; padding-bottom:20px;">
<div class="steps-list">
<div id="id-ac4e5818" class="steps-option done">
<div class="graphics-wrapper">
<div class="graphics-container"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M256,0C114.84,0,0,114.84,0,256S114.84,512,256,512,512,397.16,512,256,397.16,0,256,0ZM389.23,170.2,223.82,367.13a19.71,19.71,0,0,1-14.77,7h-.34a19.67,19.67,0,0,1-14.63-6.52l-70.89-78.77a19.69,19.69,0,1,1,28.65-27c.21.23.42.45.62.68l55.74,61.94L359.08,144.87a19.69,19.69,0,0,1,30.15,25.33Z">
</path>
</svg></div>
</div>
<div class="text-container">
<div class="label">Take Survey</div>
</div>
</div>
<div id="id-7dd41b07" class="steps-option current">
<div class="graphics-wrapper">
<div class="graphics-container"><svg data-name="Layer 1" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<defs></defs>
<path d="M419,256A163,163,0,1,0,256,419,163,163,0,0,0,419,256Z"></path>
<path d="M494,256C494,124.6,387.4,18,256,18S18,124.6,18,256,124.6,494,256,494,494,387.4,494,256Z" style="fill: none; stroke: currentColor; stroke-miterlimit: 10; stroke-width: 32px;"></path>
</svg></div>
</div>
<div class="text-container">
<div class="label">Get Setup</div>
</div>
</div>
<div id="id-56d989f2" class="steps-option">
<div class="graphics-wrapper">
<div class="graphics-container"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path d="M419,256A163,163,0,1,0,256,419,163,163,0,0,0,419,256Z"></path>
</svg></div>
</div>
<div class="text-container">
<div class="label">Get Your Benefits</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-381b9b68-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-381b9b68">Source</label>
<div class="input">
<div style="display:flex;">
<div style="flex:1;position:relative;"><input id="id-381b9b68" data-type="input" data-label="source" data-variable="source" data-mask="" name="id-381b9b68" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="">
<div class="input-floating-label"><span>Source</span></div>
</div>
</div><datalist id="datalist-id-381b9b68">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-3f6f0da6">
<div class="rich-text" style="padding-top:20px; padding-right:30px; padding-bottom:20px; padding-left:30px;">
<h4>Leave your contact information and our community partners will contact you with next steps!</h4>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="elements">
<div class="block-content elements-container elements-v1-container flex-box inner-full bg-unset border-unset br-unset mobile-flex-col" data-type="nested-blocks">
<div style="justify-content:normal; align-items:stretch; flex-direction:column; margin-right:auto; margin-left:auto; padding-top:0px; padding-bottom:0px;" class="elements-container-inner inner-narrow" data-type="template-blocks-container">
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="padding-bottom:5px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal;align-items:center;flex-direction:row;gap:10px;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="id-5095410a-container">
<div style=""><label for="id-5095410a">Legal first name</label>
<div class="input">
<div style="display:flex;">
<div style="flex:1;position:relative;"><input id="id-5095410a" data-type="input" data-label="first_name" data-variable="" data-mask="" name="id-5095410a" placeholder="Max" pattern="" maxlength="" required="required"
autofocus="" autocomplete="off" class="">
<div class="input-floating-label"><span>Legal first name</span></div>
</div>
</div><datalist id="datalist-id-5095410a">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter your first name</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="id-1069a6b8-container">
<div style=""><label for="id-1069a6b8">Legal last name</label>
<div class="input">
<div style="display:flex;">
<div style="flex:1;position:relative;"><input id="id-1069a6b8" data-type="input" data-label="last_name" data-variable="" data-mask="" name="id-1069a6b8" placeholder="Muster" pattern="" maxlength="" required="required"
autocomplete="off" class="">
<div class="input-floating-label"><span>Legal last name</span></div>
</div>
</div><datalist id="datalist-id-1069a6b8">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter your last name</span></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="id-412450ec-container">
<div style="padding-top:5px; padding-bottom:5px;"><label for="id-412450ec">Email address</label>
<div class="input has-prefix">
<div style="display:flex;">
<div class="input-decorator input-prefix input-prefix-icon"><i class="material-icons" icon="mail_outline">mail_outline</i></div>
<div style="flex:1;position:relative;"><input id="id-412450ec" data-type="input" data-label="email" data-variable="" data-mask="" name="id-412450ec" placeholder="" pattern="^\S+@\S+\.\S+$" maxlength="" data-trim=""
autocomplete="email" class="">
<div class="input-floating-label"><span>Email address</span></div>
</div>
</div><datalist id="datalist-id-412450ec">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter a valid email address</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="id-cd65cb4c-container">
<div style="padding-top:5px; padding-bottom:5px;"><label for="id-cd65cb4c">Mobile phone number</label>
<div class="input has-prefix">
<div style="display:flex;">
<div class="input-decorator input-prefix input-prefix-icon"><i class="material-icons" icon="phone">phone</i></div>
<div style="flex:1;position:relative;"><input type="tel" id="id-cd65cb4c" data-type="input" data-label="phone" data-variable="" data-mask="phone-number-us" name="id-cd65cb4c" placeholder="" pattern="^\d{3}\s\d{3}\s\d{4}$"
maxlength="12" data-trim="" required="required" autocomplete="tel" class="">
<div class="input-floating-label"><span>Mobile phone number</span></div>
</div>
</div><datalist id="datalist-id-cd65cb4c">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter a valid phone number</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="id-c433ac4b-container">
<div style="padding-top:5px; padding-right:0px; padding-bottom:5px;"><label for="id-c433ac4b">ZIP Code</label>
<div class="input has-prefix">
<div style="display:flex;">
<div class="input-decorator input-prefix input-prefix-svg"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24">
<defs></defs>
<title>pin</title>
<path d="M12,.71a7.5,7.5,0,0,1,7.5,7.5c0,3.547-5.5,12.381-7.079,14.85a.5.5,0,0,1-.842,0C10,20.592,4.5,11.757,4.5,8.21A7.5,7.5,0,0,1,12,.71Z"
style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></path>
<circle cx="12" cy="8.21" r="3" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></circle>
</svg></div>
<div style="flex:1;position:relative;"><input id="id-c433ac4b" data-type="input" data-label="zip" data-variable="" data-mask="only-numbers" name="id-c433ac4b" placeholder="" pattern="\d{5,}" maxlength="5" data-trim=""
required="required" autofocus="" autocomplete="off" class="">
<div class="input-floating-label"><span>ZIP Code</span></div>
</div>
</div><datalist id="datalist-id-c433ac4b">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter 5 digit zip code</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-on-nav" id="input-2a139924-container">
<div style="padding-top:5px; padding-bottom:5px;"><label for="input-2a139924">Date of Birth (MM-DD-YYYY)</label>
<div class="input has-prefix">
<div style="display:flex;">
<div class="input-decorator input-prefix input-prefix-svg"><svg id="Raw" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<rect x="40" y="40" width="176" height="176" rx="8" stroke-width="16" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" fill="none"></rect>
<line x1="176" y1="24" x2="176" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="16"></line>
<line x1="80" y1="24" x2="80" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="16"></line>
<line x1="40" y1="88" x2="216" y2="88" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="16"></line>
</svg></div>
<div style="flex:1;position:relative;"><input type="tel" id="input-2a139924" data-type="input" data-label="DOB" data-variable="" data-mask="date-us-dash" name="input-2a139924" placeholder="31.05.2022" pattern="" maxlength=""
data-trim="" required="required" class="">
<div class="input-floating-label"><span>Date of Birth (MM-DD-YYYY)</span></div>
</div>
</div><datalist id="datalist-input-2a139924">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter a valid date</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="input-26c76e23-container">
<div style="padding-top:5px; padding-bottom:5px;"><label for="input-26c76e23">Medi-Cal Insurance Member ID # (9 digits)</label>
<div class="input has-prefix">
<div style="display:flex;">
<div class="input-decorator input-prefix input-prefix-svg"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24">
<defs></defs>
<title>credit-card-1</title>
<rect x="0.504" y="4" width="23" height="16" rx="2" ry="2" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></rect>
<line x1="0.504" y1="8" x2="23.504" y2="8" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
<line x1="20.504" y1="12" x2="17.504" y2="12" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
<line x1="11.504" y1="12" x2="3.504" y2="12" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
<line x1="6.504" y1="15" x2="3.504" y2="15" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
</svg></div>
<div style="flex:1;position:relative;"><input id="input-26c76e23" data-type="input" data-label="insurance_id" data-variable="" data-mask="letters-and-numbers" name="input-26c76e23" placeholder="Placeholder"
pattern="^[0-9a-zA-Z]{9,14}$" maxlength="" data-trim="" autocomplete="off" class="">
<div class="input-floating-label"><span>Medi-Cal Insurance Member ID # (9 digits)</span></div>
</div>
</div><datalist id="datalist-input-26c76e23">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify min 9 digits</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow with-floating-label floating-label-inline show-error-instantly" id="id-deda1cb7-container">
<div style="padding-top:5px; padding-bottom:20px;"><label for="id-deda1cb7">Social Security Number (Optional) (9 digits)</label>
<div class="input has-prefix">
<div style="display:flex;">
<div class="input-decorator input-prefix input-prefix-svg"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24">
<defs></defs>
<title>credit-card-1</title>
<rect x="0.504" y="4" width="23" height="16" rx="2" ry="2" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></rect>
<line x1="0.504" y1="8" x2="23.504" y2="8" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
<line x1="20.504" y1="12" x2="17.504" y2="12" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
<line x1="11.504" y1="12" x2="3.504" y2="12" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
<line x1="6.504" y1="15" x2="3.504" y2="15" style="fill: none; stroke: currentColor; stroke-linecap: round; stroke-linejoin: round;"></line>
</svg></div>
<div style="flex:1;position:relative;"><input id="id-deda1cb7" data-type="input" data-label="ssn" data-variable="" data-mask="only-numbers" name="id-deda1cb7" placeholder="Placeholder" pattern="^\d{9}$" maxlength="9" data-trim=""
autocomplete="off" class="">
<div class="input-floating-label"><span>Social Security Number (Optional) (9 digits)</span></div>
</div>
</div><datalist id="datalist-id-deda1cb7">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="simple-checkbox-v2">
<div class="block-content simple-checkbox simple-checkbox-block inner-narrow" id="simple-checkbox-block-id-8b730c34">
<div style="padding-top:5px; padding-bottom:5px;"><label for="id-8b730c34"><input type="checkbox" hey-type="simple-checkbox" data-type="simple-checkbox" id="id-8b730c34" name="id-8b730c34" data-label="agreed_to_terms" data-answer="Yes"
value="Yes" required="required">
<div class="simple-checkbox-content" style="display:flex;"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span>
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English * Español * Tiếng Việt GET MATCHED TO LIFE-CHANGING BENEFITS AVAILABLE THROUGH YOUR HEALTH PLAN AND COMMUNITY PARTNERS. house-2 Housing and Transition Services Help find, pay for, and move into a safe home hospital-house Short-Term Recovery Services Get back up on your feet after an illness vegetables-salad Healthy Food & Meals Prepared meals delivered to your doorstep phone-chatting Unlimited Talk & Text Get a smartphone and data plan wireless-payment-credit-card Online SNAP EBT Marketplace Use your CalFresh EBT card online and get free delivery love-it-bubble Independent Living Support Get help with learning to cook, clean and shop CalFresh EBT Enrollment Get help signing up for CalFresh benefits restaurant-menu Nutrition Education & Recipes Help manage your health Counseling Services Speak with someone to help get through hard times vegetables-salad Nutritious Meals & Groceries Prepared meals delivered to your doorstep love-it-bubble Independent Living Support Get help with learning to cook, clean and shop house-2 Housing & Transition Services Help find, pay for, and move into a safe home hospital-house Short-Term Recovery Services Get back up on your feet after an illness phone-chatting Unlimited Talk & Text Get a free smartphone and data plan add-circle And more... Counseling services, CalFresh enrollment, etc. Device Device Option 1Option 2 Please specify an answer Referred by Referred by Option 1Option 2 Please specify an answer Get matched (Less than 2 min) SEE IF YOUR QUALIFY FOR 12 WEEKS OF FREE HEALTHY FOOD DELIVERED TO YOUR DOORSTEP. SEE IF YOU QUALIFY FOR 12 WEEKS OF FREE GROCERIES DELIVERED TO YOUR DOORSTEP Or get matched to one of these other benefits Housing Transition & Navigation Services Short-Term Recovery Services Caregiver Support Data Plan with Talk & Text CalFresh Enrollment And more... Qualify Now (Less than 2 min) Provided By Housing Transition & Navigation Services Short-Term Recovery Services Caregiver Support Data Plan with Talk & Text CalFresh Enrollment Lifeskills Education Counseling And more... WHO IS YOUR HEALTH PLAN PROVIDER? 1 2 3 4 5 6 1 I don't see my provider 2 I don't have insurance WHO IS YOUR HEALTH PLAN PROVIDER? Enter your provider Please specify an answer Next DO YOU HAVE ANY OF THESE CHRONIC DISEASES? SELECT ALL THAT APPLY, THEN CLICK NEXT 1 Alcohol Use 2 Arthritis 3 Asthma 4 Atrial Fibrillation 5 Behavioral Health or Mental Health Issues 6 Cancer 7 COPD 8 Depression 9 Diabetes 10 Heart Disease 11 Hepatitis 12 High Cholesterol 13 HIV/AIDS 14 High Blood Pressure 15 High BMI (e.g. Overweight) 16 Kidney Disease 17 Maternal Health 18 Osteoporosis 19 Stroke 20 Substance Use Next 1 I have other chronic diseases 1 I don't have a chronic disease DO YOU HAVE A HARD TIME CONTROLLING YOUR ASTHMA? 1 Yes 2 No WHAT OTHER CHRONIC DISEASES DO YOU HAVE? Type in your diseases Please specify an answer Next HAVE YOU RECENTLY LEFT ANY OF THESE FACILITIES? 1 Hospital 2 Nursing Facility 3 Recuperative Care Center 4 Substance Abuse Treatment Center 5 Correctional Facility 6 Mental Health Treatment Center 1 None of these apply to me ARE YOU AT RISK OF ENTERING INTO EITHER OF THESE FACILITIES? 1 Hospital 2 Nursing Facility 1 I don't think so ARE YOU FACING EITHER OF THESE SITUATIONS? 1 I Live in a Nursing Facility 2 I Live at Home and I Need Help Caring for Myself 1 Neither of these apply to me ARE YOU RECEIVING MEDICALLY NECESSARY CARE IN THIS NURSING FACILITY? 1 Yes 2 No HAVE YOU LIVED THERE FOR MORE THAN 60 DAYS? 1 Yes 2 No WOULD YOU LIKE TO MOVE OUT OF YOUR NURSING FACILITY AND STILL RECEIVE MEDICALLY NECESSARY CARE? 1 Yes 2 No DO YOU NEED ASSISTANCE CARING FOR YOURSELF BUT DON'T HAVE ANYONE WHO CAN HELP YOU? 1 Yes 2 No ARE YOU APPROVED OR PENDING APPROVAL FOR IN-HOME SUPPORTIVE SERVICES? 1 Yes 2 No 1 Not sure DO YOU DEPEND ON AN UNPAID CAREGIVER TO SUPPORT YOUR DAILY LIFE? 1 Yes 2 No ARE YOU FACING ANY OF THESE SITUATIONS? 1 I'm Homeless 2 I Could Become Homeless 3 I Recently Stopped Being Homeless 1 None of these apply to me HAVE YOU RECEIVED HOUSING TRANSITION NAVIGATION SERVICES? 1 Yes 2 No 1 Not sure ARE YOU PRIORITIZED FOR PERMANENT SUPPORTIVE HOUSING OR A RENTAL SUBSIDY? 1 Yes 2 No 1 Not sure DO YOU HAVE ACCESS TO A REFRIGERATOR? 1 Yes 2 No ARE YOU GETTING FOOD DELIVERED TO YOUR HOME THROUGH A COMMUNITY PROGRAM? 1 Yes 2 No ARE YOU ON A SPECIAL DIET? SUCH AS VEGETARIAN, KOSHER, OR GLUTEN-FREE 1 Yes 2 No ARE YOU ON CALFRESH? 1 Yes 2 No 1 Not sure ARE YOU ENROLLED IN ANY OF THE FOLLOWING PROGRAMS? 1 Section 8 Federal Public Housing Assistance (FPHA) 2 Supplemental Security Income (SSI) 3 National School Lunch Program's Free Lunch 4 The Veterans Pension or Survivors Pension 5 Low Income Home Energy Assistance Plan (LIHEAP) 6 Temporary Assistance for Needy Families (TANF) 1 None of these ARE YOU ENROLLED IN ANY OF THE FOLLOWING PROGRAMS? 1 Tribally-Administered Temporary Assistance for Needy Families (TTANF) 2 Bureau of Indian Affairs General Assistance 3 Food Distribution Program on Indian Reservations (FDPIR) 4 Women, Infants, and Children Program (WIC) 5 California Work Opportunity and Responsibility to Kids (CalWORKs) 6 Head Start Income Eligible (Tribal Only) 7 
Greater Avenues for Independence (GAIN) 1 None of these ARE YOU INTERESTED IN LEARNING MORE ABOUT ANY OF THESE SERVICES Select all that apply and press next. 1 Case Management Work with a team of experts to get connected to services 2 Family Support Services Crisis intervention & service referrals tailored to families 3 Domestic Violence Support Educational support on breaking the cycle of violence 4 LGBTQ+ Resources Find clinical and social support for the LGBTQ+ Community 5 Emergency Assistance Get needed support to deal with a crisis and get stable 6 Information & Referral Services Get referrals to basic services tailored to your situation 7 Parenting Education Access education on positive parenting techniques 8 Diaper Assistance Program Receive free diapers for your newborn or baby Next 1 I'm not interested in any of these services WHAT LANGUAGE DO YOU PREFER TO SPEAK IN? 1 English 2 Spanish 3 Vietnamese 4 Other WHAT LANGUAGE DO YOU PREFER TO SPEAK IN? Please specify an answer Next MATCHING YOU TO BENEFITS 🎉 JUST GIVE US A MOMENT SUCCESS! WE'VE FOUND ONE OR MORE FREE SERVICES YOU COULD BE ELIGIBLE FOR. Take Survey Get Setup Get Your Benefits Source Source Option 1Option 2 Please specify an answer LEAVE YOUR CONTACT INFORMATION AND OUR COMMUNITY PARTNERS WILL CONTACT YOU WITH NEXT STEPS! Legal first name Legal first name Option 1Option 2 Please enter your first name Legal last name Legal last name Option 1Option 2 Please enter your last name Email address mail_outline Email address Option 1Option 2 Please enter a valid email address Mobile phone number phone Mobile phone number Option 1Option 2 Please enter a valid phone number ZIP Code pin ZIP Code Option 1Option 2 Please enter 5 digit zip code Date of Birth (MM-DD-YYYY) Date of Birth (MM-DD-YYYY) Option 1Option 2 Please enter a valid date Medi-Cal Insurance Member ID # (9 digits) credit-card-1 Medi-Cal Insurance Member ID # (9 digits) Option 1Option 2 Please specify min 9 digits Social Security Number (Optional) (9 digits) credit-card-1 Social Security Number (Optional) (9 digits) Option 1Option 2 Please specify an answer I agree with the terms and conditions and also happily agree to being referred to Community Supports providers by CalAssist and to receive communications about this. Submit WE'VE GOT YOUR BACK! OUR MISSION IS TO MATCH AND CONNECT YOU WITH LIFE-CHANGE BENEFITS LIKE SHORT-TERM RECOVERY SERVICES, MEDICALLY-TAILORED FOOD AND EDUCATION, HOUSING TRANSITION SERVICES, FREE DATA PLANS, DISCOUNTED PRESCRIPTIONS AND MORE. Rate your experience: ionicons-v5-e ionicons-v5-e ionicons-v5-e ionicons-v5-e ionicons-v5-e ERROR SORRY, YOUR RESPONSE COULD NOT BE SENT. PLEASE CHECK YOUR INTERNET CONNECTION. * CalAssist - Learn More * Terms of Use * Privacy Policy AN ERROR OCCURRED. Activate JavaScript if you have it deactivated in your browser.