awt.placedreferrals.com Open in urlscan Pro
67.227.252.81 Public Scan

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URL:
https://awt.placedreferrals.com/
Submission: On November 28 via api (November 28th 2023, 12:13:35 am UTC) from US — Scanned from US

Form analysis
1 forms found in the DOM

POST /

<form id="clientreferralform" class="pr-30" method="post" action="/" autocomplete="off">
  <div class="row">
    <div class="col-lg-12">
      <p>Client Information</p>
    </div>
  </div>
  <div class="row">
    <div class="col-lg-3 col-sm-6 col-xs-12 mb-20">
      <label>*Client First Name</label>
      <input class="form-control" type="text" maxlength="25" name="CLIENT_FIRST" value="" onfocus="this.select()">
    </div>
    <div class="col-lg-3 col-sm-6 col-xs-12 mb-20">
      <label>*Client Last Name</label>
      <input class="form-control" type="text" maxlength="35" name="CLIENT_LAST" value="" onfocus="this.select()">
    </div>
    <div class="col-lg-3 col-sm-6 col-xs-12 mb-20">
      <label>Gender</label>
      <select name="CLIENT_GENDER" class="form-control">
        <option value=""></option>
        <option value="Male">Male</option>
        <option value="Female">Female</option>
      </select>
    </div>
    <div class="col-lg-3 col-sm-6 col-xs-12 mb-20">
      <label>Client Phone</label>
      <input class="form-control maskthephone2" type="text" maxlength="12" placeholder="___-___-____" name="CLIENT_PHONE" value="" onfocus="this.select()">
    </div>
  </div>
  <div class="row">
    <div class="col-sm-6 col-xs-12 mb-20">
      <label>Client Email</label>
      <input class="form-control" type="text" maxlength="80" name="CLIENT_EMAIL" value="" onfocus="this.select()">
    </div>
    <div class="col-sm-4 col-xs-6 mb-20">
      <label>Client City</label>
      <input class="form-control" type="text" maxlength="50" name="CLIENT_CITY" value="" placeholder="ex: Seattle" onfocus="this.select()">
    </div>
    <div class="col-sm-2 col-xs-6 mb-20">
      <label>*Client State</label>
      <select name="CLIENT_STATE" class="form-control">
        <option value="">Select State</option>
        <option value="AK">AK</option>
        <option value="AL">AL</option>
        <option value="AR">AR</option>
        <option value="AZ">AZ</option>
        <option value="CA">CA</option>
        <option value="CO">CO</option>
        <option value="CT">CT</option>
        <option value="DC">DC</option>
        <option value="DE">DE</option>
        <option value="FL">FL</option>
        <option value="GA">GA</option>
        <option value="HI">HI</option>
        <option value="IA">IA</option>
        <option value="ID">ID</option>
        <option value="IL">IL</option>
        <option value="IN">IN</option>
        <option value="KS">KS</option>
        <option value="KY">KY</option>
        <option value="LA">LA</option>
        <option value="MA">MA</option>
        <option value="MD">MD</option>
        <option value="ME">ME</option>
        <option value="MI">MI</option>
        <option value="MN">MN</option>
        <option value="MO">MO</option>
        <option value="MS">MS</option>
        <option value="MT">MT</option>
        <option value="NC">NC</option>
        <option value="ND">ND</option>
        <option value="NE">NE</option>
        <option value="NH">NH</option>
        <option value="NJ">NJ</option>
        <option value="NM">NM</option>
        <option value="NV">NV</option>
        <option value="NY">NY</option>
        <option value="OH">OH</option>
        <option value="OK">OK</option>
        <option value="OR">OR</option>
        <option value="PA">PA</option>
        <option value="RI">RI</option>
        <option value="SC">SC</option>
        <option value="SD">SD</option>
        <option value="TN">TN</option>
        <option value="TX">TX</option>
        <option value="UT">UT</option>
        <option value="VA">VA</option>
        <option value="VT">VT</option>
        <option value="WA">WA</option>
        <option value="WI">WI</option>
        <option value="WV">WV</option>
        <option value="WY">WY</option>
      </select>
    </div>
  </div>
  <div class="row">
    <div class="col-sm-4">
      <div class="form-group">
        <label>Dementia</label>
        <select name="DEMENTIA" class="form-control">
          <option value=""></option>
          <option value="No">No</option>
          <option value="Yes">Yes</option>
        </select>
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Language</label>
        <select name="LANGUAGE" class="form-control">
          <option value=""></option>
          <option value="1">English</option>
          <option value="8">Arabic</option>
          <option value="12">Bengali</option>
          <option value="9">Chinese</option>
          <option value="36">Czech</option>
          <option value="33">Dutch</option>
          <option value="34">Farsi</option>
          <option value="2">Filipino</option>
          <option value="3">French</option>
          <option value="4">German</option>
          <option value="35">Greek</option>
          <option value="22">Gujarati</option>
          <option value="23">Haitian Creole</option>
          <option value="39">Hausa</option>
          <option value="40">Hiligaynon</option>
          <option value="13">Hindi</option>
          <option value="38">Hungarian</option>
          <option value="14">Italian</option>
          <option value="10">Japanese</option>
          <option value="5">Korean</option>
          <option value="24">Louisiana Creole French</option>
          <option value="21">Mandarin Chinese</option>
          <option value="30">Marathi</option>
          <option value="25">Navajo</option>
          <option value="28">Persian</option>
          <option value="19">Polish</option>
          <option value="26">Portuguese</option>
          <option value="20">Punjabi</option>
          <option value="31">Romanian</option>
          <option value="6">Russian</option>
          <option value="37">Somali</option>
          <option value="7">Spanish</option>
          <option value="18">Tagalog</option>
          <option value="15">Tamil</option>
          <option value="17">Telugu</option>
          <option value="32">Thai</option>
          <option value="29">Turkish</option>
          <option value="27">Ukrainian</option>
          <option value="16">Urdu</option>
          <option value="11">Vietnamese</option>
        </select>
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Ethnicity</label>
        <select name="ETHNICITY" class="form-control">
          <option value=""></option>
          <option value="2">African American</option>
          <option value="3">Asian</option>
          <option value="1">Caucasian</option>
          <option value="5">Mixed Race</option>
          <option value="4">Native American</option>
          <option value="6">Other</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-sm-4">
      <div class="form-group">
        <label>Date of Birth</label>
        <input type="date" name="DOB" id="dob" value="" placeholder="MM/DD/YYYY" class="form-control">
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Weight (lbs)</label>
        <input type="number" name="WEIGHT" value="" class="form-control" min="0">
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Height</label>
        <div class="row">
          <div class="col-6 px-3">
            <select name="HEIGHT_FEET" class="form-control">
              <option value="0">Feet</option>
              <option value="4">4 ft</option>
              <option value="5">5 ft</option>
              <option value="6">6 ft</option>
              <option value="7">7 ft</option>
            </select>
          </div>
          <div class="col-6 pl-3">
            <select name="HEIGHT_INCHES" class="form-control">
              <option value="0">Inches</option>
              <option value="0">0 in</option>
              <option value="0.5">0.5 in</option>
              <option value="1">1 in</option>
              <option value="1.5">1.5 in</option>
              <option value="2">2 in</option>
              <option value="2.5">2.5 in</option>
              <option value="3">3 in</option>
              <option value="3.5">3.5 in</option>
              <option value="4">4 in</option>
              <option value="4.5">4.5 in</option>
              <option value="5">5 in</option>
              <option value="5.5">5.5 in</option>
              <option value="6">6 in</option>
              <option value="6.5">6.5 in</option>
              <option value="7">7 in</option>
              <option value="7.5">7.5 in</option>
              <option value="8">8 in</option>
              <option value="8.5">8.5 in</option>
              <option value="9">9 in</option>
              <option value="9.5">9.5 in</option>
              <option value="10">10 in</option>
              <option value="10.5">10.5 in</option>
              <option value="11">11 in</option>
              <option value="11.5">11.5 in</option>
            </select>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-sm-4">
      <div class="form-group">
        <label>Chronic Care Management</label>
        <select name="CCM" class="form-control">
          <option value=""></option>
          <option value="1">Yes</option>
          <option value="0">No</option>
        </select>
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Remote Patient Monitoring</label>
        <select name="RPM" class="form-control">
          <option value=""></option>
          <option value="1">Yes</option>
          <option value="0">No</option>
        </select>
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Smoker</label>
        <select name="SMOKER" class="form-control">
          <option value=""></option>
          <option value="1">Yes</option>
          <option value="0">No</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-sm-4">
      <div class="form-group">
        <label>Ability To Transfer</label>
        <select name="ABILITY_TO_TRANSFER" class="form-control">
          <option value=""></option>
          <option value="Independent">Independent</option>
          <option value="One Person Assist">One Person Assist</option>
          <option value="Two Person Assist">Two Person Assist</option>
          <option value="Hoyer Lift">Hoyer Lift</option>
        </select>
      </div>
    </div>
    <div class="col-sm-4">
      <div class="form-group">
        <label>Behavioral Problems</label>
        <select name="BEHAVIORAL_PROBLEMS" class="form-control">
          <option value=""></option>
          <option value="None">None</option>
          <option value="Mild">Mild</option>
          <option value="Moderate">Moderate</option>
          <option value="Severe">Severe</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-lg-12 mb-0">
      <p class="mb-0">Client Needs</p>
      <p class="mb-5" style="font-size:0.9em">Please check all boxes that apply</p>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Home Care"> Home Care</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Home Health"> Home Health</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Hospice Care"> Hospice Care</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Palliative Care"> Palliative Care</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Memory Care Placement"> Memory Care Placement</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Assisted Living Placement"> Assisted Living Placement</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Boarding Home Placement"> Boarding Home Placement</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="checkbox" name="CLIENT_NEEDS[]" value="Independent Living"> Independent Living</label>
    </div>
  </div>
  <div class="row">
    <div class="col-lg-12 mb-20 mt-10">
      <label>Other Client Needs</label>
      <textarea name="OTHER_SERVICES" class="form-control"></textarea>
    </div>
  </div>
  <div class="row mb-4">
    <div class="col-lg-6 col-sm-6">
      <label>Preferred Area</label>
      <input type="text" name="PREFERRED_AREA" value="" class="form-control" placeholder="ex: Seattle, WA">
    </div>
  </div>
  <div class="row">
    <div class="col-lg-12 mb-0">
      <p class="mb-0">Payment Method</p>
      <p class="mb-5" style="font-size:0.9em">Please select one (if applicable)</p>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="radio" name="PAYMETHODS" value="Private Pay"> Private Pay</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="radio" name="PAYMETHODS" value="Medicaid Approved"> Medicaid Approved</label>
    </div>
    <div class="col-md-4 col-sm-6 col-xs-12">
      <label><input type="radio" name="PAYMETHODS" value="Medicaid Waiting"> Medicaid Waiting</label>
    </div>
  </div>
  <div class="row mt-3">
    <div class="col-lg-6 col-sm-6">
      <label>Medicaid Rate, Class Rate or Private Pay LTCI Rate</label>
      <input type="text" name="MEDICAID_DAILY_RATE" value="" class="form-control" maxlength="50">
    </div>
  </div>
  <div class="row mt-3">
    <div class="col-lg-12 mb-20">
      <button type="submit" name="BUTTON" value="Continue" class="btn btn-dark btn-lg br-3">Continue&nbsp; <i class="fas fa-long-arrow-alt-right"></i></button>
      <input type="text" name="NOFILL" value="" class="nofill">
    </div>
  </div>
</form>

Text Content

SEND A REFERRAL TO AGE WELL TRANSITIONS

Phone: 978-758-2036

Step 1

Client Information
Step 2

Services & Amenities
Step 3

COVID-19 & Referral
Step 4

Complete

Client Information

*Client First Name
*Client Last Name
Gender MaleFemale
Client Phone
Client Email
Client City
*Client State Select State
AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
Dementia NoYes
Language
EnglishArabicBengaliChineseCzechDutchFarsiFilipinoFrenchGermanGreekGujaratiHaitian
CreoleHausaHiligaynonHindiHungarianItalianJapaneseKoreanLouisiana Creole
FrenchMandarin
ChineseMarathiNavajoPersianPolishPortuguesePunjabiRomanianRussianSomaliSpanishTagalogTamilTeluguThaiTurkishUkrainianUrduVietnamese
Ethnicity African AmericanAsianCaucasianMixed RaceNative AmericanOther
Date of Birth
Weight (lbs)
Height
Feet 4 ft5 ft6 ft7 ft
Inches 0 in0.5 in1 in1.5 in2 in2.5 in3 in3.5 in4 in4.5 in5 in5.5 in6 in6.5 in7
in7.5 in8 in8.5 in9 in9.5 in10 in10.5 in11 in11.5 in
Chronic Care Management YesNo
Remote Patient Monitoring YesNo
Smoker YesNo
Ability To Transfer IndependentOne Person AssistTwo Person AssistHoyer Lift
Behavioral Problems NoneMildModerateSevere

Client Needs

Please check all boxes that apply

Home Care
Home Health
Hospice Care
Palliative Care
Memory Care Placement
Assisted Living Placement
Boarding Home Placement
Independent Living
Other Client Needs
Preferred Area

Payment Method

Please select one (if applicable)

Private Pay
Medicaid Approved
Medicaid Waiting
Medicaid Rate, Class Rate or Private Pay LTCI Rate
Continue 

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awt.placedreferrals.com Open in urlscan Pro 67.227.252.81 Public Scan

Form analysis 1 forms found in the DOM

POST /

Text Content

awt.placedreferrals.com Open in urlscan Pro
67.227.252.81 Public Scan

Form analysis
1 forms found in the DOM