{"id":12935,"date":"2021-10-12T09:54:36","date_gmt":"2021-10-12T16:54:36","guid":{"rendered":"https:\/\/staging.cmhavernon.ca\/index.php\/peer-support-services\/"},"modified":"2024-03-18T13:25:31","modified_gmt":"2024-03-18T20:25:31","slug":"peer-support-services","status":"publish","type":"page","link":"https:\/\/cmhavernon.ca\/peer-support-services\/","title":{"rendered":"Peer Support Services"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Section&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;rgba(244,248,248,0.9)&#8221; background_image=&#8221;https:\/\/cmhavernon.ca\/wp-content\/uploads\/2021\/10\/Dot-Background.png&#8221; background_size=&#8221;initial&#8221; background_position=&#8221;center_left&#8221; background_blend=&#8221;lighten&#8221; animation_style=&#8221;fade&#8221; da_disable_devices=&#8221;off|off|off&#8221; border_width_bottom=&#8221;1px&#8221; border_color_bottom=&#8221;#999999&#8243; global_colors_info=&#8221;{}&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Peer Support Services<\/h1>\n<p><em>Our Peer Support service provides the opportunity for anyone \u2013 individual, family member, or professional \u2013 to speak with someone with lived experiences of mental health or substance use concerns. By engaging with our Peer Supporters, you can make a connection with someone with lived experience, increase your sense of engagement and belonging, and move through your recovery journey to develop skills and build resiliency.<\/em><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0px||||false|false&#8221; animation_style=&#8221;fade&#8221; da_disable_devices=&#8221;off|off|off&#8221; global_colors_info=&#8221;{}&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; width=&#8221;100%&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_tabs module_class=&#8221;vertical-tabs1&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_tab title=&#8221;Trans Peer Support&#8221; _builder_version=&#8221;4.17.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-13006 alignnone size-full\" src=\"\/wp-content\/uploads\/2021\/10\/trans-flag.jpg\" alt=\"\" width=\"300\" height=\"168\" style=\"font-size: 16px;\" \/><\/h2>\n<h2>Trans Peer Support<\/h2>\n<p>Trans Peer Support is a peer led community based social support service run by peers with lived experience. We offer a safe space that provides an opportunity to engage in knowledge exchange, resource sharing, social connection, mentorship and personal growth.<\/p>\n<p>Our volunteers\u00a0and those we support represent trans, gender diverse, Two-Spirit adults as well as families from the trans community.<\/p>\n<p>Meet on a 1:1 basis by phone or virtually with a trained volunteer.<\/p>\n<p class=\"has-custom-weight\">Benefits of the Trans Peer Support Program<\/p>\n<ul>\n<li>Validates experiences<\/li>\n<li>Reduces\u00a0isolation<\/li>\n<li>Provides opportunities to give and receive support<\/li>\n<li>Fosters connections and a social support network<\/li>\n<li>Confidential support<\/li>\n<\/ul>\n<p class=\"has-custom-weight\">How to Access Trans Peer Support<\/p>\n<p>If you are interested in the Trans Peer Support Program, please fill out the information below, and someone will contact you shortly.<\/p>\n<p>For further information or questions, please contact:<\/p>\n<p>Email:\u00a0<a href=\"mailto:trans.peer@cmhavernon.ca\">trans.peer@cmhavernon.ca<\/a><\/p>\n<p>Phone: Serenity Leboe at 250-542-3114 ext: 245<\/p>\n<p>Are you interested in becoming a volunteer? 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);} ); \n\/* ]]> *\/\n<\/script>\n\n<p>[\/et_pb_tab][et_pb_tab title=&#8221;Peer Support Services&#8221; _builder_version=&#8221;4.17.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h4>Peer Support Services<\/h4>\n<p>The Peer Support Program is a peer-led, community-based social support service.\u00a0 Trained volunteers offer emotional and practical support and connection between people who share common experiences.\u00a0 Peer support provides various free and confidential services, including support and education, one-on-one social activity, hospital visitation, advocacy, and leadership training.<\/p>\n<p>Our volunteers uniquely understand lived experience with a mental health diagnosis or concern. They are trained to offer support, friendship, hope and understanding to their peers in the mental health community. \u00a0Through interaction with their peers, they seek to foster:<\/p>\n<ul>\n<li>empowerment through meaningful volunteer opportunities<\/li>\n<li>awareness of resources in the community<\/li>\n<li>independence by emphasizing recovery and by being positive role models<\/li>\n<li>social connections to others and the community<\/li>\n<\/ul>\n<p>Peer Volunteers with the Hospital Program visit the VJH Mental Health Ward to provide hope, encouragement and information about the services the Peer Support Program provides.\u00a0 Volunteers can help to address concerns people with a mental illness might have through their knowledge of the rights of people who are hospitalized, the Mental Health Act, and issues affecting the day-to-day living of people coping with a mental illness.<\/p>\n<p><strong><u>Contact Peer Support Program<\/u><\/strong><\/p>\n<p>Phone: (250) 542-3114 ext. 299<br \/>E-mail: \u00a0<a href=\"\/our-services\/peer-support\/peeroutreach.vernon@cmhavernon.ca\">peeroutreach.vernon@cmhavernon.ca<\/a><\/p>\n<p>[\/et_pb_tab][et_pb_tab title=&#8221;Care to Speak&#8221; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Care to Speak<\/h2>\n<p><strong>C<\/strong><b><span data-contrast=\"none\">are to Speak<\/span><\/b><span data-contrast=\"none\">\u202foffers individuals in the Healthcare and Social Services sectors a safe space to talk. You will be connected with a trained peer supporter who has worked in front-line healthcare or the social services sector \u2013 someone who understands your challenges and stresses.\u202f<\/span><span data-ccp-props=\"{&quot;134233117&quot;:true,&quot;134233118&quot;:true,&quot;201341983&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"none\">Support is available through <\/span><span data-contrast=\"none\">online chat, text message, and telephon<\/span><span data-contrast=\"none\">e to help you through any tough times you might be experiencing. You will reach out to volunteers with experience in healthcare or\u202fthe\u202fsocial services field who are trained to provide virtual support and refer you to additional resources if needed<\/span><span data-contrast=\"none\">.\u202f<\/span><span data-ccp-props=\"{&quot;134233117&quot;:true,&quot;134233118&quot;:true,&quot;201341983&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"none\">The Care to Speak program is here to help through the tough times. Our volunteers understand the pressures of the job and have experienced similar struggles. Sometimes, talking about certain things with coworkers, family members, or friends is difficult, but Care to Speak is a safe space to share your feelings. All our support is confidential and delivered without judgment.\u202f<\/span><span data-ccp-props=\"{&quot;134233117&quot;:true,&quot;134233118&quot;:true,&quot;201341983&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"none\">We are not designed to be in stress mode all the time. When our stress-response system gets overworked, we are at increased risk of experiencing physical and mental health problems. These are unprecedented times. Know that\u202fyou are not alone<\/span><span data-contrast=\"none\">\u00a0<\/span><span data-contrast=\"none\">and that help is available.\u00a0<\/span><\/p>\n<p><span data-contrast=\"none\">Your mental health is a priority if you work in healthcare or social services. <\/span><span data-contrast=\"none\">Call, text, or chat online<\/span><span data-contrast=\"none\"> to get the support you deserve.\u202f<\/span><span data-ccp-props=\"{&quot;134233117&quot;:true,&quot;134233118&quot;:true,&quot;201341983&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"none\">Call or Text:<\/span><span data-contrast=\"none\"> 1-866-802-7337 (PEER)\u202f<\/span><span><br \/><\/span><span data-contrast=\"none\">Chat online at caretospeak.ca\u202f<\/span><span><br \/><\/span><span data-contrast=\"none\">Available Monday-Friday, 9 am \u2013 9 pm <\/span><span data-contrast=\"none\">PST\u202f<\/span><span data-ccp-props=\"{&quot;134233117&quot;:true,&quot;134233118&quot;:true,&quot;201341983&quot;:0,&quot;335559740&quot;:240}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"none\">For more information or to connect with a peer supporter, click\u202f<\/span><strong><a href=\"https:\/\/www.careforcaregivers.ca\/caretospeak\/\" target=\"_blank\" rel=\"noopener\">here<\/a>\u202f\u00a0<\/strong><\/p>\n<p><span data-ccp-props=\"{&quot;134233117&quot;:true,&quot;134233118&quot;:true,&quot;201341983&quot;:0,&quot;335559740&quot;:240}\">Are you interested in becoming a volunteer? Click <strong><a href=\"\/volunteering\/\" target=\"_blank\" rel=\"noopener\">here<\/a><\/strong> to learn more about this volunteer opportunity and other opportunities.<\/span><\/p>\n<p>[\/et_pb_tab][et_pb_tab title=&#8221;Good Morning Program&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Good Morning Program<\/h2>\n<p>The Good Morning Program is a free telephone service for seniors living alone or feeling isolated. Phone calls are made Monday-Friday, including holidays, by trained volunteers. Participants can be referred by care providers, family, and friends, or self-referrals can be made.\u00a0\u00a0<\/p>\n<p>Each call is non-intrusive and non-judgmental and provides social interaction. We listen, provide support and offer referrals when needed.<\/p>\n<p>The program is free of charge and available to people living in Vernon and surrounding areas.<\/p>\n<p>If you or someone you know might benefit from this service, please call our program office at 250.542.3114 for more information.\u00a0 To get started, please complete our\u00a0<a href=\"https:\/\/cmhavernon.ca\/good-morning-program-referral\/\">program referral form. The link is above the title Good Moring Program on this page<\/a><strong>.<\/strong><\/p>\n<p>Are you interested in becoming a volunteer? Click\u00a0<a href=\"https:\/\/cmhavernon.ca\/volunteering\/\"><strong>here<\/strong><\/a>\u00a0to learn more about this volunteer opportunity and other opportunities.<\/p>\n<p><strong>Program Staff<\/strong><\/p>\n<p>Serenity Leboe \u2013 Good Morning, Program Coordinator<\/p>\n<p style=\"margin: 0cm; background: white; vertical-align: baseline;\"><span style=\"font-size: 13.5pt; font-family: 'Open Sans',sans-serif; color: black;\">Serenity.leboe@cmhavernon.ca<o:p><\/o:p><\/span><\/p>\n<p><span style=\"color: #121bce;\"><a href=\"Serenity.leboe@cmhavernon.ca\" style=\"color: #121bce;\"><\/a><\/span><\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-13007 alignnone size-full\" src=\"\/wp-content\/uploads\/2021\/10\/Low_res_Province_stacked_logo-150x150-1.jpg\" alt=\"\" width=\"150\" height=\"150\" \/><\/p>\n<p>[\/et_pb_tab][et_pb_tab title=&#8221;Good Morning Program Participant Referral&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Good Morning Program Referral Form<\/p>\n\n                <div class='gf_browser_chrome gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_32' ><div id='gf_32' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_32' id='gform_32'  action='\/wp-json\/wp\/v2\/pages\/12935#gf_32' data-formid='32' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_32' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_32_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Participant&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_32_1'>\n                            \n                            <span id='input_32_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_32_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_32_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_32_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_32_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_32_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_32_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_18\" ><label class='gfield_label gform-field-label' for='input_32_18'>Pronouns:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_32_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_2\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_2\" ><label class='gfield_label gform-field-label' for='input_32_2'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_32_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_32_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_32_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_32_2' class='gform_hidden' value='https:\/\/cmhavernon.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_32_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_3\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_32_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_32_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_32_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_32_3_1' id='input_32_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_32_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_32_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_32_3_2' id='input_32_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_32_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_32_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_32_3_3' id='input_32_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_32_3_4_container' >\n                                        <select name='input_3.4' id='input_32_3_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' selected='selected'>British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_32_3_4' id='input_32_3_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_32_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_32_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_32_3_5' id='input_32_3_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_32_3_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_32_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_17\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Preferred Method of Contact<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_32_17'><li class='gchoice gchoice_32_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Home Phone'  id='choice_32_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_17_1' id='label_32_17_1' class='gform-field-label gform-field-label--type-inline'>Home Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Cell Phone'  id='choice_32_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_17_2' id='label_32_17_2' class='gform-field-label gform-field-label--type-inline'>Cell Phone<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_7\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_7\" ><label class='gfield_label gform-field-label' for='input_32_7'>Home Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_32_7' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_32_8\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_8\" ><label class='gfield_label gform-field-label' for='input_32_8'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_32_8' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_32_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_9\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Participant\u2019s emergency contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_32_9'>\n                            \n                            <span id='input_32_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_32_9_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_32_9_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_32_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_32_9_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_32_9_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_32_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_10\" ><label class='gfield_label gform-field-label' for='input_32_10'>Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_32_10' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_32_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_11\" ><label class='gfield_label gform-field-label' for='input_32_11'>Emergency Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_32_11' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_32_13\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_13\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Referrer&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_32_13'>\n                            \n                            <span id='input_32_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_32_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_32_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_32_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_32_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_32_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_32_16\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_16\" ><label class='gfield_label gform-field-label' for='input_32_16'>Referrer&#039;s Organization<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_32_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_14\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_14\" ><label class='gfield_label gform-field-label' for='input_32_14'>Referrer&#039;s Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_32_14' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_32_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_32_15\" ><label class='gfield_label gform-field-label' for='input_32_15'>Referrer&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_32_15' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_32_19\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  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