{"id":2769,"date":"2021-03-16T00:32:28","date_gmt":"2021-03-16T04:32:28","guid":{"rendered":"https:\/\/cmhwc.com\/new\/?page_id=2769"},"modified":"2021-03-16T16:52:28","modified_gmt":"2021-03-16T20:52:28","slug":"referrals","status":"publish","type":"page","link":"https:\/\/cmhwc.com\/index.php\/referrals\/","title":{"rendered":"Referrals"},"content":{"rendered":"<style type=\"text\/css\">#nex-forms{display:none;}<\/style><div id=\"nf_form_28920\">\r\n\t\t\t\r\n\t\t\t<style type=\"text\/css\">\r\n\t\t\t\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-spinner div:after {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-grid div {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-ellipsis div { background: #40C4FF;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-default div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-roller div:after {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-heart div,\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-heart div:after,\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-heart div:before {background: #40C4FF;}\r\n\t\r\n\t\t\t\t\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-facebook div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-circle > div {background: #40C4FF;}\r\n\t\t\t\t\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-dual-ring:after {border: 6px solid #40C4FF;border-color: #40C4FF transparent #40C4FF transparent;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-ring div {border: 8px solid #40C4FF;border-color: #40C4FF transparent transparent transparent;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-hourglass:after {border: 32px solid #40C4FF;border-color: #40C4FF transparent #40C4FF transparent;}\r\n\t\t\t\t#nex-forms.cmhwc_referral_form .nf-loader-lds-ripple div {border: 4px solid #40C4FF;}\r\n\t\t\t<\/style>\r\n\t\t\t\r\n\t\t\t\r\n\t\t\t<div id=\"nex-forms\" data-loader=\"ellipsis\" data-msg-hide-form=\"yes\" data-msg-position=\"top\" data-msg-placement=\"outside\"  class=\"nex-forms cmhwc_referral_form  \"><div class=\"pre_fill_fields\"><\/div><div class=\"set_form_theme theme-base\"><div class=\"nex_success_message msg_top msgv2 animated hidden\" style=\"display:none;\"><div class=\"nex_success_message_container\" style=\"background: #fff; box-shadow: #00000033 0px 7px 16px 0px; border-radius: 4px; padding: 30px; border-color:#ddd;\"><div class=\"msg_text\"><div class=\"form_field all_fields icon html_fields wow bounceInUp\" data-settings=\".s-icon\" data-settings-tabs=\"#input-settings, #animation-settings\" style=\"margin-bottom: 15px;\" id=\"_21501\" data-animation-name=\"bounceInUp\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"icon_container_wrapper icon_center\">\n\t\t\t\t\t\t\t\t  <div class=\"icon_container\" id=\"field_container\" style=\"border-width: 0px; background-color: transparent;\">\n\t\t\t\t\t\t\t\t\t<div class=\"\">\n\t\t\t\t\t\t\t\t\t  <div class=\"input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element icon_element\" style=\"font-size: 50px; color: #8bc34a;\"><span class=\"fas fa-check-circle\"><\/span><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields html html_fields wow fadeInDown\" data-settings=\".s-html\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings, #math-settings\" style=\"margin-bottom: 15px;\" data-animation-name=\"fadeInDown\" data-wow-delay=\"0.5s\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t  <div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t  <div class=\"col-sm-12 input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Thank you for filling out our Client Referral Form.  We will be in touch.<\/div>\n\t\t\t\t\t\t\t\t\t\t<div style=\"clear:both;\"><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div data-timer-start=\"1\" data-timer-end=\"0\" class=\"inner-canvas-container ui-nex-forms-container ui-nex-forms-container-fe  bootstrap\" id=\"ui-nex-forms-container-1\"  ><div class=\"current_step\" style=\"display:none;\">1<\/div><div class=\"last_visited_step\" style=\"display:none;\">1<\/div><div class=\"nex-forms-header-footer nex-forms-header timer_inline timer_right \"><\/div><div id=\"the_plugin_url\" style=\"display:none;\">https:\/\/cmhwc.com\/wp-content\/plugins\/nex-forms<\/div><div id=\"nf_save_form_progress\" style=\"display:none;\">false<\/div><div id=\"confirmation_page\" class=\"confirmation_page\" style=\"display:none;\"><\/div><div id=\"on_form_submmision\" class=\"on_form_submmision\" style=\"display:none;\">message<\/div><div class=\"hidden\" id=\"nf_ajax_url\" style=\"display:none;\">https:\/\/cmhwc.com\/wp-admin\/admin-ajax.php<\/div><div class=\"hidden\" id=\"paypal_return_url\" style=\"display:none;\">https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/pages\/2769<\/div><div class=\"hidden\" id=\"ms_scroll_to_top\" style=\"display:none;\">yes<\/div><div class=\"v7_container form_type_normal   \" style=\"padding: 0px;\"><div class=\"current_field_on_focus\" style=\"display:none\">1<\/div><form id=\"1\" class=\"submit-nex-form nex-forms-1\" data-form-id=\"1\" name=\"nex_form\" action=\"https:\/\/cmhwc.com\/wp-admin\/admin-ajax.php\" method=\"post\" enctype=\"multipart\/form-data\"><div class=\"step_transition_in\" style=\"display:none;\">fadeIn<\/div><div class=\"step_transition_out\" style=\"display:none;\">fadeOut<\/div><input type=\"hidden\" name=\"nex_forms_Id\" value=\"1\"><input type=\"hidden\" name=\"page\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/2769\"><input type=\"hidden\" name=\"ip\" value=\"216.73.216.84\"><input type=\"hidden\" name=\"nf_page_id\" value=\"2769\"><input type=\"hidden\" name=\"nf_page_title\" value=\"Referrals\"><input type=\"text\" name=\"company_url\" value=\"\" placeholder=\"enter company url\" class=\"form-control req\">\n\t\t\t\t\t\t\t<div class=\"form_field hidden\" style=\"\" data-id=\"_11256\" id=\"_11256\">\n\t\t\t\t\t\t\t\t<input class=\"ms_current_step\" value=\"1\" name=\"ms_current_step\" type=\"hidden\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields heading html_fields\" style=\"position: relative; top: 0px;\" data-settings-tabs=\"#input-settings, #animation-settings\" data-settings=\".s-headings\" data-id=\"_70382\" id=\"_70382\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\"><h3 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element align_center\"><br>CMHWC Referral Form<br><br><\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_93459\" id=\"_93459\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Choose Service Location<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"choose_service_location_boston\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"choose_service_location\" id=\"choose_service_location_boston\" value=\"Boston\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Boston<\/span><\/span><\/label><label class=\"radio-inline \" for=\"choose_service_location_lynn\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"choose_service_location\" id=\"choose_service_location_lynn\" value=\"Lynn\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Lynn<\/span><\/span><\/label><label class=\"radio-inline \" for=\"choose_service_location_both\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"choose_service_location\" id=\"choose_service_location_both\" value=\"Both\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Both<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" style=\"position: relative; top: 0px; height: 30px;\" data-id=\"_9895\" id=\"_9895\"><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_80836\" id=\"_80836\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_80836 col-sm-7 grid-target-0\" data-grid-width=\"7\" data-grid-num=\"0\"><div class=\"form_field all_fields radio-group common_fields selection_fields required\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_40088\" id=\"_40088\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"label_container align_let align_left col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*ChooseService Type<\/span><\/label><\/div><div class=\"the-radios input_container error_message col-sm-12\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"chooseservice_type_new\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"chooseservice_type\" id=\"chooseservice_type_new\" value=\"New\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">New<\/span><\/span><\/label><label class=\"radio-inline \" for=\"chooseservice_type_re-open\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"chooseservice_type\" id=\"chooseservice_type_re-open\" value=\"Re-Open\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Re-Open<\/span><\/span><\/label><label class=\"radio-inline \" for=\"chooseservice_type_service_change\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"chooseservice_type\" id=\"chooseservice_type_service_change\" value=\"Service Change\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Service Change<\/span><\/span><\/label><label class=\"radio-inline \" for=\"chooseservice_type_additional_service\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"chooseservice_type\" id=\"chooseservice_type_additional_service\" value=\"Additional Service\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Additional Service<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_80836 col-sm-5 grid-target-1\" data-grid-width=\"5\" data-grid-num=\"1\"><div class=\"form_field all_fields radio-group common_fields selection_fields required\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_28498\" id=\"_28498\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"label_container align_let align_left col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Appointment<\/span><\/label><\/div><div class=\"the-radios input_container error_message col-sm-12\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline\" for=\"appointment_type_next_available\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"appointment\" id=\"appointment_type_next_available\" value=\"Next Available\" style=\"display: none;\"><a class=\"ui-state-default\" style=\"background: #ffffff;\"><\/a><\/div><span class=\"input-label radio-label\">Next Available<\/span><\/span><\/label><label class=\"radio-inline \" for=\"appointment_type_urgent\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"appointment\" id=\"appointment_type_urgent\" value=\"Urgent\" style=\"display: none;\"><a class=\"fa ui-state-default\" style=\"background: #ffffff;\"><\/a><\/div><span class=\"input-label radio-label\">Urgent<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" style=\"position: relative; top: 0px; height: 30px;\" data-id=\"_35092\" id=\"_35092\"><\/div><div class=\"form_field all_fields check-group common_fields selection_fields required radio-group\" data-settings=\".s-checks, .s-v-multi-selections\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 50px; position: relative; top: 0px; left: 0px;\" data-id=\"_97534\" id=\"_97534\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Choose Service: <\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__community_support_program_csp\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__community_support_program_csp\" value=\"Community Support Program (CSP)\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">Community Support Program (CSP)<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__complementary_alternative_therapy\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__complementary_alternative_therapy\" value=\"Complementary Alternative Therapy\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">Complementary Alternative Therapy<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__in_home_therapy_iht\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__in_home_therapy_iht\" value=\"In Home Therapy (IHT)\" style=\"display: none;\"><a class=\"ui-state-default\" style=\"background: #ffffff;\"><\/a><\/div><span class=\"input-label check-label\">In Home Therapy (IHT)<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__lgbtq_focused_services\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__lgbtq_focused_services\" value=\"LGBTQ Focused Services\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">LGBTQ Focused Services<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__men_focus_services\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__men_focus_services\" value=\"Men Focus Services\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">Men Focus Services<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__out_patient_op\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__out_patient_op\" value=\"Out Patient (OP)\" style=\"display: none;\"><a class=\"ui-state-default\" style=\"background: #ffffff;\"><\/a><\/div><span class=\"input-label check-label\">Out Patient (OP)<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__substance_use_disorder_sud\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__substance_use_disorder_sud\" value=\"Substance Use Disorder (SUD)\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">Substance Use Disorder (SUD)<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__therapeutic_mentoring_tm\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__therapeutic_mentoring_tm\" value=\"Therapeutic Mentoring (TM)\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">Therapeutic Mentoring (TM)<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"choose_service_type:__women_focus_services\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"choose_service:_[]\" id=\"choose_service_type:__women_focus_services\" value=\"Women Focus Services\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">Women Focus Services<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_94288\" id=\"_94288\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_94288 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields select common_fields selection_fields required\" data-settings=\".s-select\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_33533\" id=\"_33533\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Language Spoken<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><select name=\"language_spoken\" class=\"the_input_element error_message text pre-format form-control aling_left align_left required\" data-content=\"Required\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\" data-default-selected-value=\"0\" data-required=\"true\"><option value=\"0\" selected=\"selected\">--- Select ---<\/option><option value=\"English\">English<\/option><option value=\"Cape Verdean Creole\">Cape Verdean Creole<\/option><option value=\"French\">French<\/option><option value=\"Haitian Creole\">Haitian Creole<\/option><option value=\"Portuguese\">Portuguese<\/option><option value=\"Spanish\">Spanish<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_94288 col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields radio-group common_fields selection_fields\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_937\" id=\"_937\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Interpreter<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"interpreter_yes\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"interpreter\" id=\"interpreter_yes\" value=\"Yes\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Yes<\/span><\/span><\/label><label class=\"radio-inline \" for=\"interpreter_no\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"interpreter\" id=\"interpreter_no\" value=\"No\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_94288 col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields select common_fields selection_fields\" data-settings=\".s-select\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_56086\" id=\"_56086\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Ethnicity<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><select name=\"ethnicity\" class=\"the_input_element error_message text pre-format form-control aling_left align_left\" data-content=\"Required\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\" data-default-selected-value=\"0\" data-required=\"false\"><option value=\"0\" selected=\"selected\">--- Select ---<\/option><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option value=\"White\">White<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_32424\" id=\"_32424\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_32424 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_68314\" id=\"_68314\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_left col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Client #<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"client_\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_32424 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\" style=\"\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_54127\" id=\"_54127\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_54127 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields name preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_61074\" id=\"_61074\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Your Name<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix \" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fas fa-user\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"your_name\" class=\"error_message required form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_54127 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields has_prefix_icon\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_77214\" id=\"_77214\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_left col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Your Agency<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fas fa-building\"><\/span><\/span><input type=\"text\" name=\"your_agency\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_3441\" id=\"_3441\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_3441 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields phone_number phone_number preset_fields required has_prefix_icon\" data-settings=\".s-text,s-phone, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_42673\" id=\"_42673\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Your Phone Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix \" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa fa-phone\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"your_phone_number\" class=\"error_message required phone_number form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_3441 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields email email preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_9542\" id=\"_9542\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Your Email<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix \" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fas fa-envelope\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"your_email\" class=\"error_message required email form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid email address\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" style=\"height: 50px;\" data-id=\"_33665\" id=\"_33665\"><\/div><div class=\"other-elements is_panel has_prefix_icon is_grid\" data-settings=\".s-panel\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_70976\" id=\"_70976\"><div class=\"row\"><div class=\"input_holder col-sm-12\"><div class=\"panel panel-default \"><div class=\"panel-heading\">Client Information<\/div><div class=\"panel-body the-panel-body\" style=\"\"><div class=\"grid-system-2 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_56151\" id=\"_56151\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_56151 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields name preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_738\" id=\"_738\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let col-sm-12\"><label class=\"nf_title \"><span class=\"the_label\">*Client First Name<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fa fa-user\"><\/span><\/span><input type=\"text\" name=\"client_first_name\" class=\"error_message required form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" style=\"background-position: left 0%; font-size: 15px;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_56151 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields name preset_fields required has_prefix_icon moving_batch\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_60275\" id=\"_60275\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let col-sm-12\"><label class=\"nf_title \"><span class=\"the_label\">*Client Last Name<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fa fa-user\"><\/span><\/span><input type=\"text\" name=\"client_last_name\" class=\"error_message required  form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_10756\" id=\"_10756\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_10756 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"grid-system-2 is_grid\" style=\"position: relative; top: 0px;\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" data-settings=\".s-grid\" data-id=\"_75594\" id=\"_75594\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_75594 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields paragraph html_fields\" style=\"position: relative; top: 0px; left: 0px;\" data-settings-tabs=\"#input-settings, #animation-settings, #math-settings\" data-settings=\".s-paragraph\" data-id=\"_1484\" id=\"_1484\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"font-size: 14px; color: #9e9e9e;\">*Date of Birth<\/div><div style=\"clear:both;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_75594 col-sm-8 grid-target-1\" data-grid-width=\"8\" data-grid-num=\"1\"><div class=\"grid-system-3 is_grid\" style=\"position: relative; top: 0px; left: 0px;\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" data-settings=\".s-grid\" data-id=\"_36458\" id=\"_36458\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_36458 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields select common_fields selection_fields required\" data-settings=\".s-select\" style=\"position: relative; top: 0px; left: 0px;\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" data-id=\"_79840\" id=\"_79840\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-10\"><select name=\"reason_for_unemployment\" class=\"the_input_element error_message text pre-format form-control  aling_left align_left required\" data-content=\"Required\" data-default-selected-value=\"0\" data-required=\"true\"><option value=\"0\" selected=\"selected\">Day<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_36458 col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields select common_fields selection_fields required\" data-settings=\".s-select\" style=\"position: relative; top: 0px; left: 0px;\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" data-id=\"_63633\" id=\"_63633\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><select name=\"month\" class=\"the_input_element error_message text pre-format form-control  aling_left required\" data-content=\"Required\" data-default-selected-value=\"0\" data-required=\"true\"><option value=\"0\" selected=\"selected\">Month<\/option><option value=\"1\">January<\/option><option value=\"2\">February<\/option><option value=\"3\">March<\/option><option value=\"4\">April<\/option><option value=\"5\">May<\/option><option value=\"6\">June<\/option><option value=\"7\">July<\/option><option value=\"8\">August<\/option><option value=\"9\">September<\/option><option value=\"10\">October<\/option><option value=\"11\">November<\/option><option value=\"12\">December<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_36458 col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields select common_fields selection_fields required\" data-settings=\".s-select\" style=\"position: relative; top: 0px; left: 0px;\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" data-id=\"_45681\" id=\"_45681\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><select name=\"year\" class=\"the_input_element error_message text pre-format form-control  aling_left required\" data-content=\"Required\" data-default-selected-value=\"0\" data-required=\"true\"><option value=\"0\" selected=\"selected\">Year<\/option><option value=\"2020\">2020<\/option><option value=\"2019\">2019<\/option><option value=\"2018\">2018<\/option><option value=\"2017\">2017<\/option><option value=\"2016\">2016<\/option><option value=\"2015\">2015<\/option><option value=\"2014\">2014<\/option><option value=\"2013\">2013<\/option><option value=\"2012\">2012<\/option><option value=\"2011\">2011<\/option><option value=\"2010\">2010<\/option><option value=\"2009\">2009<\/option><option value=\"2008\">2008<\/option><option value=\"2007\">2007<\/option><option value=\"2006\">2006<\/option><option value=\"2005\">2005<\/option><option value=\"2004\">2004<\/option><option value=\"2003\">2003<\/option><option value=\"2002\">2002<\/option><option value=\"2001\">2001<\/option><option value=\"2000\">2000<\/option><option value=\"1999\">1999<\/option><option value=\"1998\">1998<\/option><option value=\"1997\">1997<\/option><option value=\"1996\">1996<\/option><option value=\"1995\">1995<\/option><option value=\"1994\">1994<\/option><option value=\"1993\">1993<\/option><option value=\"1992\">1992<\/option><option value=\"1991\">1991<\/option><option value=\"1990\">1990<\/option><option value=\"1989\">1989<\/option><option value=\"1988\">1988<\/option><option value=\"1987\">1987<\/option><option value=\"1986\">1986<\/option><option value=\"1985\">1985<\/option><option value=\"1984\">1984<\/option><option value=\"1983\">1983<\/option><option value=\"1982\">1982<\/option><option value=\"1981\">1981<\/option><option value=\"1980\">1980<\/option><option value=\"1979\">1979<\/option><option value=\"1978\">1978<\/option><option value=\"1977\">1977<\/option><option value=\"1976\">1976<\/option><option value=\"1975\">1975<\/option><option value=\"1974\">1974<\/option><option value=\"1973\">1973<\/option><option value=\"1972\">1972<\/option><option value=\"1971\">1971<\/option><option value=\"1970\">1970<\/option><option value=\"1969\">1969<\/option><option value=\"1968\">1968<\/option><option value=\"1967\">1967<\/option><option value=\"1966\">1966<\/option><option value=\"1965\">1965<\/option><option value=\"1964\">1964<\/option><option value=\"1963\">1963<\/option><option value=\"1962\">1962<\/option><option value=\"1961\">1961<\/option><option value=\"1960\">1960<\/option><option value=\"1959\">1959<\/option><option value=\"1958\">1958<\/option><option value=\"1957\">1957<\/option><option value=\"1956\">1956<\/option><option value=\"1955\">1955<\/option><option value=\"1954\">1954<\/option><option value=\"1953\">1953<\/option><option value=\"1952\">1952<\/option><option value=\"1951\">1951<\/option><option value=\"1950\">1950<\/option><option value=\"1949\">1949<\/option><option value=\"1948\">1948<\/option><option value=\"1947\">1947<\/option><option value=\"1946\">1946<\/option><option value=\"1945\">1945<\/option><option value=\"1944\">1944<\/option><option value=\"1943\">1943<\/option><option value=\"1942\">1942<\/option><option value=\"1941\">1941<\/option><option value=\"1940\">1940<\/option><option value=\"1939\">1939<\/option><option value=\"1938\">1938<\/option><option value=\"1937\">1937<\/option><option value=\"1936\">1936<\/option><option value=\"1935\">1935<\/option><option value=\"1934\">1934<\/option><option value=\"1933\">1933<\/option><option value=\"1932\">1932<\/option><option value=\"1931\">1931<\/option><option value=\"1930\">1930<\/option><option value=\"1929\">1929<\/option><option value=\"1928\">1928<\/option><option value=\"1927\">1927<\/option><option value=\"1926\">1926<\/option><option value=\"1925\">1925<\/option><option value=\"1924\">1924<\/option><option value=\"1923\">1923<\/option><option value=\"1922\">1922<\/option><option value=\"1921\">1921<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_10756 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_91327\" id=\"_91327\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Social Security (Last 4)<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"social_security_last_4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-1 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_75535\" id=\"_75535\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_75535 col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields has_prefix_icon required\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_1376\" id=\"_1376\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_left col-sm-1\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Address<\/span><\/label><\/div><div class=\"input_container col-sm-11\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fas fa-map-signs\"><\/span><\/span><input type=\"text\" name=\"address\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_64488\" id=\"_64488\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_64488 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_34228\" id=\"_34228\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_left col-sm-3\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*City<\/span><\/label><\/div><div class=\"input_container col-sm-9\"><input type=\"text\" name=\"city\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_64488 col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields select common_fields selection_fields required\" data-settings=\".s-select\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_17128\" id=\"_17128\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_left col-sm-3\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*State<\/span><\/label><\/div><div class=\"input_container col-sm-9\"><select name=\"state\" class=\"the_input_element error_message text pre-format form-control aling_left align_left required\" data-content=\"Required\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\" data-default-selected-value=\"0\" data-required=\"true\"><option value=\"0\" selected=\"selected\">--- Select ---<\/option><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennsylvania\">Pennsylvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_64488 col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields required\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_2509\" id=\"_2509\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_left col-sm-2\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Zip <\/span><\/label><\/div><div class=\"input_container col-sm-10\"><input type=\"text\" name=\"zip_\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_14309\" id=\"_14309\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_14309 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields radio-group common_fields selection_fields required\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_380\" id=\"_380\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Sex<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"sex_female\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"sex\" id=\"sex_female\" value=\"Female\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Female<\/span><\/span><\/label><label class=\"radio-inline \" for=\"sex_male\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"sex\" id=\"sex_male\" value=\"Male\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Male<\/span><\/span><\/label><label class=\"radio-inline \" for=\"sex_transgender\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"sex\" id=\"sex_transgender\" value=\"Transgender\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Transgender<\/span><\/span><\/label><label class=\"radio-inline \" for=\"sex_other\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"sex\" id=\"sex_other\" value=\"Other\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_14309 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\" style=\"\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_82709\" id=\"_82709\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_82709 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields phone_number phone_number preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" style=\"position: relative; top: 0px;\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" data-id=\"_77736\" id=\"_77736\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let col-sm-12\"><label class=\"nf_title \"><span class=\"the_label\">*Home Phone <\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fa fa-phone\"><\/span><\/span><input type=\"text\" name=\"home_phone_\" class=\"error_message required phone_number form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_82709 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields phone_number phone_number preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" style=\"position: relative; top: 0px; left: 0px;\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" data-id=\"_36437\" id=\"_36437\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let col-sm-12\"><label class=\"nf_title \"><span class=\"the_label\">*Cell Phone <\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fa fa-phone\"><\/span><\/span><input type=\"text\" name=\"cell_phone_\" class=\"error_message required phone_number form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_93825\" id=\"_93825\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_93825 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields name preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_40180\" id=\"_40180\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let col-sm-12\"><label class=\"nf_title \"><span class=\"the_label\">*Parent\/Guardian Name<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\"><span class=\"input-group-addon prefix\"><span class=\"fa fa-user\"><\/span><\/span><input type=\"text\" name=\"parentguardian_name\" class=\"error_message required form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" style=\"background-position: left 0%; font-size: 15px;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_93825 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields textarea common_fields\" data-settings=\".s-text, .s-texarea, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_70473\" id=\"_70473\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Special Considerations \/ Requests<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"special_considerations__requests\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" style=\"position: relative; top: 0px; height: 50px;\" data-id=\"_33508\" id=\"_33508\"><\/div><div class=\"other-elements is_panel has_prefix_icon is_grid\" data-settings=\".s-panel\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_30776\" id=\"_30776\"><div class=\"row\"><div class=\"input_holder col-sm-12\"><div class=\"panel panel-default \"><div class=\"panel-heading\">Insurance Information<\/div><div class=\"panel-body the-panel-body\" style=\"\"><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_79544\" id=\"_79544\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_79544 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_85655\" id=\"_85655\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Primary Insurance<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"primary_insurance\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_79544 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_9542\" id=\"_9542\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Insurance Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"insurance_number\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_22147\" id=\"_22147\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_22147 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_54562\" id=\"_54562\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Secondary Insurance<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"secondary_insurance\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_22147 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_36016\" id=\"_36016\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Insurance Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"insurance_number\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_66321\" id=\"_66321\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_66321 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields date special_fields has_prefix_icon\" data-settings=\".s-date, .s-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_59522\" id=\"_59522\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Authorized Start Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"MM\/DD\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"authorized_start_date\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_66321 col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields date special_fields has_prefix_icon\" data-settings=\".s-date, .s-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_15225\" id=\"_15225\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Authorized End Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"MM\/DD\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"authorized_end_date\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_66321 col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_9820\" id=\"_9820\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Units Approved<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"units_approved\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_81709\" id=\"_81709\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_81709 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_70853\" id=\"_70853\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Authorized Approval Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"authorized_approval_number\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_81709 col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\" style=\"\"><\/div><\/div><\/div><div class=\"grid_input_holder id-_81709 col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"panel-default\"><div class=\"panel-body\" style=\"\"><\/div><\/div><\/div><\/div><\/div><div class=\"other-elements is_panel is_grid\" data-settings=\".s-panel\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_91579\" id=\"_91579\"><div class=\"row\"><div class=\"input_holder col-sm-12\"><div class=\"panel panel-default \"><div class=\"panel-heading\">Axis 1<\/div><div class=\"panel-body the-panel-body\" style=\"\"><div class=\"grid-system-3 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_25453\" id=\"_25453\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_25453 col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_35087\" id=\"_35087\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Dx1<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"dx1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_25453 col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_28472\" id=\"_28472\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Dx2<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"dx2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_25453 col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" data-id=\"_38876\" id=\"_38876\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Dx3<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"dx3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_79785\" id=\"_79785\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_79785 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields radio-group common_fields selection_fields\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_28212\" id=\"_28212\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Insurance Status<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"insurance_status_eligible\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"insurance_status\" id=\"insurance_status_eligible\" value=\"Eligible\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Eligible<\/span><\/span><\/label><label class=\"radio-inline \" for=\"insurance_status_not_eligible\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"insurance_status\" id=\"insurance_status_not_eligible\" value=\"Not Eligible\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Not Eligible<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_79785 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\" style=\"\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" data-settings=\".s-text, .s-texarea, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_68975\" id=\"_68975\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Reason For Referral<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"reason_for_referral\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_33136\" id=\"_33136\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_33136 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields radio-group common_fields selection_fields required\" data-settings=\".s-radios\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_68952\" id=\"_68952\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Has client received past services?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"has_client_received_past_services_yes\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"has_client_received_past_services\" id=\"has_client_received_past_services_yes\" value=\"Yes\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Yes<\/span><\/span><\/label><label class=\"radio-inline \" for=\"has_client_received_past_services_no\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"has_client_received_past_services\" id=\"has_client_received_past_services_no\" value=\"No\" style=\"display: none;\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_33136 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields select common_fields selection_fields\" data-settings=\".s-select\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_37534\" id=\"_37534\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">Services received before<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><select name=\"service_received_before\" class=\"the_input_element error_message text pre-format form-control aling_left align_left\" data-content=\"Required\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\" data-default-selected-value=\"0\"><option value=\"0\" selected=\"selected\">--- Select ---<\/option><option value=\"Community Support Program (CSP)\">Community Support Program (CSP)<\/option><option value=\"Complementary Alternative Therapy\">Complementary Alternative Therapy<\/option><option value=\"In Home Therapy (IHT)\">In Home Therapy (IHT)<\/option><option value=\"LGBTQ Focused Services\">LGBTQ Focused Services<\/option><option value=\"Men Focus Services\">Men Focus Services<\/option><option value=\"Out Patient (OP)\">Out Patient (OP)<\/option><option value=\"Substance Use Disorder (SUD)\">Substance Use Disorder (SUD)<\/option><option value=\"Therapeutic Mentoring (TM)\">Therapeutic Mentoring (TM)<\/option><option value=\"Women Focus Services\">Women Focus Services<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-1 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; top: 0px;\" data-id=\"_67836\" id=\"_67836\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_67836 col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"form_field all_fields check-group common_fields selection_fields required radio-group\" data-settings=\".s-checks, .s-v-multi-selections\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_75173\" id=\"_75173\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Disclaimer and Signature<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"check_boxes_i_certify_that_my_answers_are_true_and_complete_to_the_best_of_my_knowledge_if_this_application_leads_to_employment_i_understand_that_false_or_misleading_information_in_my_application_or_interview_may_result_in_my_release\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element required\" type=\"checkbox\" name=\"disclaimer_and_signature[]\" id=\"check_boxes_i_certify_that_my_answers_are_true_and_complete_to_the_best_of_my_knowledge_if_this_application_leads_to_employment_i_understand_that_false_or_misleading_information_in_my_application_or_interview_may_result_in_my_release\" value=\"I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.\" style=\"display: none;\"><a class=\"ui-state-default\" style=\"background: #ffffff;\"><\/a><\/div><span class=\"input-label check-label\">I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"\" data-id=\"_50328\" id=\"_50328\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_50328 col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields name preset_fields required has_prefix_icon\" data-settings=\".s-text, .s-v-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_81711\" id=\"_81711\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Name<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix \" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fas fa-user\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"_name\" class=\"error_message required form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_50328 col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields date special_fields has_prefix_icon required\" data-settings=\".s-date, .s-text\" data-settings-tabs=\"#label-settings, #input-settings, #validation-settings, #animation-settings, #extra-settings\" style=\"margin-bottom: 15px;\" data-id=\"_94110\" id=\"_94110\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #9e9e9e;\">*Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"MM\/DD\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date\" class=\"error_message form-control the_input_element aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #9e9e9e; background: white; border-color: #dddddd;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-1 is_grid\" data-settings=\".s-grid\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" style=\"position: relative; left: 0px; top: 0px;\" data-id=\"_52213\" id=\"_52213\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_52213 col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"form_field all_fields submit-button the_submit button_fields common_fields preset_fields special_fields selection_fields\" style=\"position: relative; top: 0px; margin-bottom: 50px; margin-top: 30px;\" data-settings-tabs=\"#input-settings, #animation-settings, #extra-settings\" data-settings=\".s-submit\" data-id=\"_53012\" id=\"_53012\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><button class=\"nex-submit svg_ready the_input_element btn btn-default col-sm-12\" data-ga=\"\" style=\"background-color: #e5e5e5;\">Submit Referral<\/button><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" style=\"height: 70px;\" data-id=\"_60206\" id=\"_60206\"><\/div><\/form><\/div><\/div><\/div><\/div><\/div><style type=\"text\/css\" class=\"nex-forms-custom-css\">.job_application_head {\n    margin-top: -46px;\n}<\/style>\n","protected":false},"excerpt":{"rendered":"Thank you for filling out our Client Referral Form. We will be in touch. 11https:\/\/cmhwc.com\/wp-content\/plugins\/nex-formsfalsemessagehttps:\/\/cmhwc.com\/wp-admin\/admin-ajax.phphttps:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/pages\/2769yes1fadeInfadeOut CMHWC Referral Form*Choose Service LocationBostonLynnBoth*ChooseService TypeNewRe-OpenService ChangeAdditional Service*AppointmentNext AvailableUrgent*Choose Service: Community Support Program (CSP)Complementary Alternative TherapyIn Home Therapy (IHT)LGBTQ Focused ServicesMen Focus ServicesOut Patient (OP)Substance Use Disorder (SUD)Therapeutic Mentoring (TM)Women Focus Services*Language Spoken--- Select ---EnglishCape Verdean CreoleFrenchHaitian CreolePortugueseSpanishInterpreterYesNoEthnicity--- Select ---American &hellip; <a href=\"https:\/\/cmhwc.com\/index.php\/referrals\/\" class=\"more-link\">Continue reading <span class=\"screen-reader-text\">Referrals<\/span><\/a>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2769","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/pages\/2769","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/comments?post=2769"}],"version-history":[{"count":3,"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/pages\/2769\/revisions"}],"predecessor-version":[{"id":2810,"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/pages\/2769\/revisions\/2810"}],"wp:attachment":[{"href":"https:\/\/cmhwc.com\/index.php\/wp-json\/wp\/v2\/media?parent=2769"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}