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[contact-form][contact-field label=’Client Name’ type=’name’ required=’1’/][contact-field label=’Contact Name’ type=’name’ required=’1’/][contact-field label=’Phone’ type=’text’ required=’1’/][contact-field label=’City’ type=’text’ required=’1’/][contact-field label=’Email’ type=’email’/][contact-field label=’Primary Disability (if applicable)’ type=’text’/][contact-field label=’Schedule (days of the week/hours of the day/24 hour)’ type=’text’/][contact-field label=’Service Need as of (date)’ type=’text’/][contact-field label=’Medicaid or Private Pay’ type=’select’ options=’Select Oneā€¦,Private Pay: 24/7 Hourly Care,Private Pay: Live-In Care,Medicaid PCA Minor: PCA U21,Medicaid Waiver: Lifeskills Level 1 (formerly companion),Medicaid Waiver: Lifeskills Level 2 (formerly supported employment),Medicaid Waiver: Personal Support (day),Medicaid Waiver: Personal Support (qtrh),Medicaid Waiver: Supported Living Consultation,Other (notes in comments)’/][contact-field label=’Comment / Description of Service Needed’ type=’textarea’ required=’1’/][/contact-form]