COI Home Condition Assessment

On [date name="date" default="Today"] Care Coordinator [text name="CC" default="Your name"] visited the home of Caregiver [text name="Caregiver" default="CG's name"] to conduct a home conditions assessment. The Caregiver stated that they [checkbox name="Rent_Own" value="rent|own|are living for free in"] their [checkbox name="Type_of_home" value="single family home=single_family_home|apartment|townhouse/duplex|shelter"][textarea name="other_type_of_home" memo="other types of home" default="" rows="1"]. The Caregiver explained that the home has [checkbox name="bedrooms" value="1 bedroom|2 bedrooms|3 bedrooms|4 bedrooms| 5 bedrooms"][textarea name="other_bedrooms" memo="other bedrooms" default="" rows="1"], the number of children living there is [checkbox name="number_of_children" value="1|2|3|4|5|6|7|8"][textarea name="more_than_eight_children" memo="if more than 8 kids" default="" rows="1"] and the number of adults living there is [checkbox name="number_of_adults" value="1|2|3|4|5|6|7|8"][textarea name="more_than_eight_adults" memo="if more than 8 adults" default="" rows="1"]. 
The exterior of the home was [checkbox name="Ext_Home_Cond" value="in excellent condition|in good condition|in average condition|in poor condition|in very poor condition|unable to be observed by the Care Coordinator"]. The the interior of the home was [checkbox name="Int_Home_Cond" value="in excellent condition|in good condition|in average condition|in poor condition|in very poor condition|unable to be observed by the Care Coordinator"]. Overall the home was [checkbox name="Home_Condition" value="in excellent condition|in good condition|in average condition|in poor condition|in very poor condition|unable to be reported by the Care Coordinator due to not having seen the entire home"]. The Caregiver reported that the neighborhood is [checkbox name="neighborhood" value="very safe|safe|somewhat safe|somewhat dangerous|dangerous|very dangerous"] and they are [checkbox name="satisfaction" value="very satisfied with their home|satisfied with their home|looking but are in no rush to find a new place|actively looking to move as soon as possible"].
The Caregiver also explained that they are [checkbox name="finance" value="able to pay their housing expenses|unable to pay their housing expenses and need assistance"].
Regarding home security, Care coordinator noticed [checkbox name="security_specialties" value="bullet holes|a notice for foreclosure|broken or unsecured windows/doors|an alarm system|security cameras|a watch dog|that there was nothing that was of concern"] and that the overall security and safety of the home is [checkbox name="Sec_rate" value="excellent|good|average|poor|very bad"].
[comment memo="What is the Care Coordinators plan for the future?"] 
Care Coordinator will [textarea name="plan" default=" "]
On Care Coordinator visited the home of Caregiver to conduct a home conditions assessment. The Caregiver stated that they their other types of home. The Caregiver explained that the home has other bedrooms, the number of children living there is if more than 8 kids and the number of adults living there is if more than 8 adults.
The exterior of the home was . The the interior of the home was . Overall the home was . The Caregiver reported that the neighborhood is and they are .
The Caregiver also explained that they are .
Regarding home security, Care coordinator noticed and that the overall security and safety of the home is .
What is the Care Coordinators plan for the future?
Care Coordinator will

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 22 form elements, 96 boilerplate words, 2 text boxes, 5 text areas, 1 dates, 13 checkboxes, 1 comments, 78 total clicks
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