{"id":298,"date":"2024-06-07T09:40:52","date_gmt":"2024-06-07T09:40:52","guid":{"rendered":"https:\/\/demolinks2.com\/baffour-agyeman\/?page_id=298"},"modified":"2024-06-07T12:55:23","modified_gmt":"2024-06-07T12:55:23","slug":"op-intake-packet-mfs","status":"publish","type":"page","link":"https:\/\/demolinks2.com\/baffour-agyeman\/op-intake-packet-mfs\/","title":{"rendered":"OP Intake Packet MFS"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row woodmart_css_id=&#8221;66630321a282d&#8221; responsive_spacing=&#8221;eyJwYXJhbV90eXBlIjoid29vZG1hcnRfcmVzcG9uc2l2ZV9zcGFjaW5nIiwic2VsZWN0b3JfaWQiOiI2NjYzMDMyMWEyODJkIiwic2hvcnRjb2RlIjoidmNfcm93IiwiZGF0YSI6eyJ0YWJsZXQiOnt9LCJtb2JpbGUiOnt9fX0=&#8221; mobile_bg_img_hidden=&#8221;no&#8221; tablet_bg_img_hidden=&#8221;no&#8221; woodmart_parallax=&#8221;0&#8243; woodmart_gradient_switch=&#8221;no&#8221; woodmart_box_shadow=&#8221;no&#8221; wd_z_index=&#8221;no&#8221; woodmart_disable_overflow=&#8221;0&#8243; row_reverse_mobile=&#8221;0&#8243; row_reverse_tablet=&#8221;0&#8243;][vc_column]\t\t<div id=\"wd-666303305c9dd\" class=\"wd-image wd-wpb wd-rs-666303305c9dd text-center  op-tntk-img\">\n\t\t\t\n\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"1239\" height=\"938\" src=\"https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01.png\" class=\"attachment-full size-full\" alt=\"\" srcset=\"https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01.png 1239w, https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01-300x227.png 300w, https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01-1024x775.png 1024w, https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01-768x581.png 768w\" sizes=\"auto, (max-width: 1239px) 100vw, 1239px\" \/>\n\t\t\t\t\t<\/div>\n\t\t[\/vc_column][\/vc_row][vc_row el_id=&#8221;op-tntk-rowxxx&#8221; woodmart_css_id=&#8221;6662d60740110&#8243; responsive_spacing=&#8221;eyJwYXJhbV90eXBlIjoid29vZG1hcnRfcmVzcG9uc2l2ZV9zcGFjaW5nIiwic2VsZWN0b3JfaWQiOiI2NjYyZDYwNzQwMTEwIiwic2hvcnRjb2RlIjoidmNfcm93IiwiZGF0YSI6eyJ0YWJsZXQiOnt9LCJtb2JpbGUiOnt9fX0=&#8221; mobile_bg_img_hidden=&#8221;no&#8221; tablet_bg_img_hidden=&#8221;no&#8221; woodmart_parallax=&#8221;0&#8243; woodmart_gradient_switch=&#8221;no&#8221; woodmart_box_shadow=&#8221;no&#8221; wd_z_index=&#8221;no&#8221; woodmart_disable_overflow=&#8221;0&#8243; row_reverse_mobile=&#8221;0&#8243; row_reverse_tablet=&#8221;0&#8243;][vc_column]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/298' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">bioClient Information<\/h3><\/div><fieldset id=\"field_3_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_3'>\n                            \n                            <span id='input_3_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_3_4' >\n                        <span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_3_4_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_4_2' id='input_3_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_3_4_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_4_3' id='input_3_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_4.4' id='input_3_4_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_3_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_3_4_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_4_5' id='input_3_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_3_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'>Cell\/Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_3_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>Alternate Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_3_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Marital Status<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>DOB<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>SS#<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_11\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_12'>Referral Source<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_3_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_3_13' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Primary Care Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_3_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Psychiatrist<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_3_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_3_17' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Parent\/Guardian (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>Patient\/Guardian Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'>Client\u2019s Primary Insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_3_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_21\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_21'>Policy #<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_22\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Policy Holder Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_22'>\n                            \n                            <span id='input_3_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.3' id='input_3_22_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_22_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_23\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>DOB<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_3_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_24\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_24'>Secondary Insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_25\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>Policy #<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_3_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_26\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_26'>Reason for Seeking Services<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_3_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Appointment Reminders<\/h3><div class='gsection_description' id='gfield_description_3_27'>Please check the box with your preferred method to be notified of your appointment date & time\n(Only select one option)\n<\/div><\/div><div id=\"field_3_28\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Reminders may be given up to 3 days in advance depending on the date of your appointment<\/b>\\<\/div><fieldset id=\"field_3_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email Reminder<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_39'><div class='gchoice gchoice_3_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Email Reminder'  id='choice_3_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_39_1' id='label_3_39_1' class='gform-field-label gform-field-label--type-inline'>Email Reminder<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_40\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_40'>Appont-Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_3_40' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_3_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Phone Call<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_42'><div class='gchoice gchoice_3_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Phone Call'  id='choice_3_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_42_1' id='label_3_42_1' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_43\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_43'>Appont-phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_43' id='input_3_43' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are Voicemails with Appt. Time &amp; Date OK?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_44'><div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Yes'  id='choice_3_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='No'  id='choice_3_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_2' id='label_3_44_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >No Reminder<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_45'><div class='gchoice gchoice_3_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='No Reminder'  id='choice_3_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_1' id='label_3_45_1' class='gform-field-label gform-field-label--type-inline'>No Reminder<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><div id=\"field_3_47\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_47'>Client\/Guardian Signature\/Print<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_47_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_47_valid' id='input_3_47_valid' \/><canvas id='input_3_47' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_48\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Relationship to Client<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_49\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_49'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_49' id='input_3_49' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_49_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_49_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_49' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_50\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CLIENT\u2019S FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS<\/h3><\/div><fieldset id=\"field_3_51\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_51'>\n                            \n                            <span id='input_3_51_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_51.3' id='input_3_51_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_51_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_52\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_52'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_3_52' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_52_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_52' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_53\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_53'>Insurance Company(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_3_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Assignment of Insurance Benefits<\/h3><div class='gsection_description' id='gfield_description_3_54'>I hereby authorize RESILIENCE PSYCHIATRY AND WELLNESS to furnish to the above-mentioned insurance company(s) with requested information. <\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I hereby assign to Multicultural Family Solutions, LLC all money to which I am entitled for medical expenses related to the services rendered by my therapist, but not to exceed my financial obligation. It is understood that any money received from the above-named insurance company, over & above my obligation will be refunded either to me or my insurance company when my bill is paid in full. I agree to pay my co-payment\/deductible at the time of service.<\/div><div id=\"field_3_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Self-Pay Rates<\/h3><\/div><div id=\"field_3_57\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><table>\n  <tr>\n    <th>Assessment<\/th>\n    <th>Rate<\/th>\n  <\/tr>\n  <tr>\n    <td><ul><li>Evaluation<\/li><\/ul><\/td>\n    <td>$175.00<\/td>\n  <\/tr>\n  <\/table>\n  <table>\n  <tr>\n    <th>Outpatient Services<\/th>\n\n  <\/tr>\n  <tr>\n    <td><ul><li>Individual Therapy<\/li><\/ul><\/td>\n    <td>$150 \/60 min session<\/td>\n  <\/tr>\n  <tr>\n    <td><ul><li>Family\/Marital Therapy<\/li><\/ul><\/td>\n    <td>$150.00\/60 min session<\/td>\n  <\/tr>\n  <tr>\n    <td><ul><li>Tele-Health (Therapy)<\/li><\/ul><\/td>\n    <td>$150.00\/60 min session<\/td>\n  <\/tr>\n  <\/table><\/div><div id=\"field_3_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Please read then initial each statement below<\/h3><\/div><div id=\"field_3_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full intail-stmnt field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_61'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_3_61' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_61\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_61'>I hereby agree it is my responsibility to advise RESILIENCE PSYCHIATRY AND WELLNESS of any insurance changes in a timely manner. This will allow Multicultural Family Solutions time to obtain appropriate authorizations to be received prior to my appointment.<\/div><\/div><div id=\"field_3_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full intail-stmnt field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_3_62' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_62\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_62'>Failure to notify Multicultural Family Solutions of insurance changes may result in a denial of services which will become your full financial responsibility. <\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full intail-stmnt field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_3_63' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_63\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_63'>I hereby agree that I am financially responsible for all non-covered charges, at the rates listed above for Outpatient Therapy Services. <\/div><\/div><div id=\"field_3_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full intail-stmnt field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_3_64' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_64\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_64'>I further agree, in the event of nonpayment, to bear the cost of collections and\/or court cost & reasonable legal fees should this be required.<\/div><\/div><div id=\"field_3_65\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Make checks payable to:Multicultural Family Solutions, LLC<\/div><fieldset id=\"field_3_66\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Name (Print)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_66'>\n                            \n                            <span id='input_3_66_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.3' id='input_3_66_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_66_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_67\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_67'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_67_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_67_valid' id='input_3_67_valid' \/><canvas id='input_3_67' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_68\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_68'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_68' id='input_3_68' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_68_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_68_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_68' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_69\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Name (Print)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_69'>\n                            \n                            <span id='input_3_69_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_69.3' id='input_3_69_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_69_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_70\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_70'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_70_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_70_valid' id='input_3_70_valid' \/><canvas id='input_3_70' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_71\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_71'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_3_71' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_71_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_71_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_71' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_72\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Resilience Psychiatry and Wellness Representative (Print)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_72'>\n                            \n                            <span id='input_3_72_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_72.3' id='input_3_72_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_72_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_73\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_73'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_73_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_73_valid' id='input_3_73_valid' \/><canvas id='input_3_73' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_74\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_74'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_74' id='input_3_74' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_74_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_74_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_74' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_76\" class=\"gfield gfield--type-section gfield--input-type-section gsection outpatnt field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Outpatient Therapy Cancellation and Missed Appointment Policy<\/h3><\/div><div id=\"field_3_75\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >In order to provide the best quality of care, we request that you provide Multicultural Family Solutions, LLC with 24 hours\u2019 notice if you need to cancel or reschedule an appointment. Failure to do so may result in a $50.00 fee per cancelled\/missed appointment. Cancelling\/missing three appointments without 24 hours\u2019 notice in a six-month period may result in termination of services. Please feel free to speak to your provider if you have any questions concerning this policy.<\/div><div id=\"field_3_158\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I have read the above statement and agree to abide by the policy as stated above. <\/div><fieldset id=\"field_3_78\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Name (Print)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_78'>\n                            \n                            <span id='input_3_78_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.3' id='input_3_78_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_78_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_79\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_79'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_79_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_79_valid' id='input_3_79_valid' \/><canvas id='input_3_79' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_80\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_80'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_3_80' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_80_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_80_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_80' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_81\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Name (Print)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_81'>\n                            \n                            <span id='input_3_81_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_81.3' id='input_3_81_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_81_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_82\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_82'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_82_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_82_valid' id='input_3_82_valid' \/><canvas id='input_3_82' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_83\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_83'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_83' id='input_3_83' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_83_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_83_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_83' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_84\" class=\"gfield gfield--type-section gfield--input-type-section gsection notc-prctse field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Notice of Privacy Practices<\/h3><div class='gsection_description' id='gfield_description_3_84'>THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.<\/div><\/div><div id=\"field_3_86\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full plse-revew gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Your health record contains personal information about you and your health.  Multicultural Family Solutions, LLC (MFS)is committed to protecting this medical information. Upon request, we will provide you a copy of the full HIPAA regulations.<\/div><div id=\"field_3_87\" class=\"gfield gfield--type-section gfield--input-type-section gsection may-use field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:<\/h3><\/div><div id=\"field_3_89\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full for-trt gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>For Treatment and health care operations\u2013<\/b>To coordinate your treatment within our agency.<\/div><div id=\"field_3_90\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full for-trt gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>For Payment. <\/b> MFS may use or disclose medical information so that we can receive payment for the treatment services provided to you.<\/div><div id=\"field_3_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full for-trt gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Substance Abuse Information.<\/b> All medical information regarding substance abuse is kept strictly confidential and disclosed only in accordance with federal regulation (42 CFR part 2)<\/div><div id=\"field_3_92\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full for-trt gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>As Required by Law.<\/b>\nFollowing is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.\n<\/div><div id=\"field_3_93\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full law-table gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><table>\n  <tr>\n    <td>Abuse and Neglect<\/td>\n    <td>Judicial and Administrative Proceedings<\/td>\n  <\/tr>\n  <tr>\n    <td>Emergencies<\/td>\n    <td>Law Enforcement<\/td>\n  <\/tr>\n  <tr>\n    <td>National Security<\/td>\n    <td>Public Safety (Duty to Warn)<\/td>\n  <\/tr>\n<\/table><\/div><div id=\"field_3_94\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full for-trt gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Verbal Permission.<\/b>  We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.<\/div><div id=\"field_3_95\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full for-trt gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>With Authorization.<\/b>  Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.<\/div><div id=\"field_3_96\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_96'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_96_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_96_valid' id='input_3_96_valid' \/><canvas id='input_3_96' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_97\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_97'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_97' id='input_3_97' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_97_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_97_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_97' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_98\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_98'>Parent\/Guardian Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_98_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_98_valid' id='input_3_98_valid' \/><canvas id='input_3_98' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_99\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_99'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_99' id='input_3_99' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_99_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_99_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_99' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_100'>Resilience Psychiatry and Wellness Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_3_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_101\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_101'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_101' id='input_3_101' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_101_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_101_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_101' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_102\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION<\/h3><\/div><div id=\"field_3_103\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >You have the following rights regarding your personal medical information maintained by our MFS to exercise any of these rights, please submit your request in writing to your Baffour Agyema-Duah, at \nBaffour.Agyeman-Duah@resiliencepsychiatryandwellness.com<\/div><div id=\"field_3_104\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>1) Right of Access to Inspect and Copy.<\/b>  You have the right, which may be restricted only in exceptional circumstances, to inspect and copy medical information that may be used to make decisions about your care.  We may charge a reasonable, cost-based fee for copies.<\/div><div id=\"field_3_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>2) Right to an Accounting of Disclosures and to request restrictions. <\/b> <\/div><div id=\"field_3_106\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>3) Right to Request Confidential Communication.<\/b> You have the right to request that we communicate with you about medical matters in a certain way or at a certain location\u2019<\/div><div id=\"field_3_107\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>4) Right to a Copy of this Notice. <\/b> You have the right to a copy of this full Notice and the privacy regulations<\/div><div id=\"field_3_108\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>5) Electronic Transactions Standards.<\/b> All electronic transmissions follow MFS established security guidelines necessary to protect your confidentiality.<\/div><div id=\"field_3_109\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_109'>Client Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_109_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_109_valid' id='input_3_109_valid' \/><canvas id='input_3_109' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_110\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_110'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_110' id='input_3_110' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_110_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_110_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_110' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_113\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_113'>Parent\/Guardian Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_113_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_113_valid' id='input_3_113_valid' \/><canvas id='input_3_113' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_114\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_114'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_114' id='input_3_114' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_114_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_114_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_114' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_115\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_115'>Resilience Psychiatry and Wellness Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_3_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_116\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_116'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_116' id='input_3_116' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_116_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_116_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_116' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_117\" class=\"gfield gfield--type-section gfield--input-type-section gsection rght-reponsv field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Rights and Responsibilities<\/h3><\/div><div id=\"field_3_118\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Each consumer has a right to exercise his\/her legal, civil, and human rights, including constitutional rights, statutory rights and the rights contained in this document, except where specifically limited. Your rights are assured and protected in the code of Virginia (12 VAC35-115).You have a right to know what they are and we will freely give you a copy, and review with you, the entire chapter in the code of Virginia detailing your rights, the complaint process and appeals process.<\/div><div id=\"field_3_119\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >1. Be able to exercise your legal, civil and human rights related to the receipt of these services.\n2. Receive services that are provided consistent with sound therapeutic practices.\n3. To have your human dignity respected and be protected from harm, including abuse, neglect, exploitation, retaliation and humiliation.\n4. Have access to your records and pertinent information in a timely manner to assist with making decisions regarding these services.\n5. Receive prompt evaluation and person-centered treatment which includes you in the development of your individualized service plan.\n6. Not be the subject of experimental or investigational research without your prior written and informed consent or that of your authorized representative.\n7. Be treated under the least restrictive conditions consistent with your well-being and not be subjected to physical restraint, isolation and seclusion beyond the constraints of our Handle with Care Non-Violent Restraint Intervention Policy. \n8. Have access and be referred to legal entities for appropriate representation, self-help and\/or advocacy support services. \n9. You may file a complaint with your human rights advocate.  Their role is to help protect your rights and to make sure you are being treated fairly. <\/div><div id=\"field_3_120\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Ann Pascoe Tel.  804.297.1503; Email:  ann.Pascoe@dbhds.virginia.gov<\/div><div id=\"field_3_121\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >1. Attend as scheduled and participate fully and honestly in counseling and therapeutic service activities;\n2. Remain available for appointments with their MFS counselor(s);\n3. Refrain from the use of any abusive, vulgar, obscene or demeaning language;\n4. Refrain from any harassing, aggressive, threatening or assaultive conduct towards others to include the use of weapons and\/ or firearms; \n5. Refrain from the use of illegal or legal substances to include drugs, tobacco, alcohol or prescription medications during services; \n6. Respect the property and right of others.\n<\/div><div id=\"field_3_122\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><div id=\"field_3_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_123'>Client<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_3_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_125\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_125'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_125' id='input_3_125' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_125_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_125_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_125' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_126\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_126'>Parent or Authorized Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_3_126' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_127\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_127'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_127' id='input_3_127' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_127_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_127_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_127' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_128'>Resilience Psychiatry and Wellness Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_3_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_129\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_129'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_129' id='input_3_129' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_129_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_129_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_129' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_130\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><div id=\"field_3_131\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Insurance plans and managed care organizations (MCO) encourage the exchange of information between Multicultural Family Solutions and your Primary Care Physician (PCP) as well as other service providers to coordinate medical and psychiatric care. <\/div><fieldset id=\"field_3_132\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please make a selection below:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_132'><div class='gchoice gchoice_3_132_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.1' type='checkbox'  value='I give consent for information regarding my treatment to be shared with my PCP\/Referring Physician\/Pediatrician\/Therapist\/Psychiatrist as follows:'  id='choice_3_132_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_132_1' id='label_3_132_1' class='gform-field-label gform-field-label--type-inline'>I give consent for information regarding my treatment to be shared with my PCP\/Referring Physician\/Pediatrician\/Therapist\/Psychiatrist as follows:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_133\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of PCP<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_133'>\n                            \n                            <span id='input_3_133_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_133.3' id='input_3_133_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_133_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_134\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_134'>PCP Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_134' id='input_3_134' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_135\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Location<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_3_135' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_135_1_container' >\n                                        <input type='text' name='input_135.1' id='input_3_135_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_135_1' id='input_3_135_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_135.4' id='input_3_135_4' value=''\/><input type='hidden' class='gform_hidden' name='input_135.6' id='input_3_135_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_136\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of Therapist<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_136'>\n                            \n                            <span id='input_3_136_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_136.3' id='input_3_136_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_136_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_137\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_137'>Therapist Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_137' id='input_3_137' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_138\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Location<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_3_138' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_138_1_container' >\n                                        <input type='text' name='input_138.1' id='input_3_138_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_138_1' id='input_3_138_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_138.4' id='input_3_138_4' value=''\/><input type='hidden' class='gform_hidden' name='input_138.6' id='input_3_138_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_139\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of Psychiatrist<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_139'>\n                            \n                            <span id='input_3_139_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_139.3' id='input_3_139_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_139_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_140\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_140'>Therapist Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_140' id='input_3_140' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_141\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Location<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_3_141' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_141_1_container' >\n                                        <input type='text' name='input_141.1' id='input_3_141_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_141_1' id='input_3_141_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_141.4' id='input_3_141_4' value=''\/><input type='hidden' class='gform_hidden' name='input_141.6' id='input_3_141_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_142\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Untitled<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_142'><div class='gchoice gchoice_3_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='I do not wish to have information regarding my treatment with this practice released to my PCP &amp; other service providers.'  id='choice_3_142_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_142_1' id='label_3_142_1' class='gform-field-label gform-field-label--type-inline'>I do not wish to have information regarding my treatment with this practice released to my PCP &amp; other service providers.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_143\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I authorize Multicultural Family Solutions to disclose current healthcare information with the family\/others listed below.<\/div><div id=\"field_3_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_144'>Spouse\/Partner<\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_3_144' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_145\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_145'>Parent<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_3_145' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_146'>Sibling<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_3_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_147\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_147'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_3_147' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_148\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_148'>Client Signature:<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_148_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_148_valid' id='input_3_148_valid' \/><canvas id='input_3_148' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_149\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_149'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_149' id='input_3_149' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_149_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_149_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_149' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_150\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_150'>Parent\/Guardian Signature:<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_150_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_150_valid' id='input_3_150_valid' \/><canvas id='input_3_150' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_151\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_151'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_151' id='input_3_151' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_151_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_151_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_151' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_152\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_152'>Resilience Psychiatry and Wellness Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_3_152' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_153\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_153'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_153' id='input_3_153' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_153_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_153_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_153' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_154\" class=\"gfield gfield--type-section gfield--input-type-section gsection Author field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Authorization for Release of Information<\/h3><\/div><div id=\"field_3_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third authr field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_155'>I,<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_3_155' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_156\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third authr field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_156'>born on<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_3_156' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_157\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >hereby authorizes Multicultural Family Solutions (MFS) to exchange information with:<\/div><fieldset id=\"field_3_159\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_159'>\n                            \n                            <span id='input_3_159_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_159.3' id='input_3_159_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_159_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_160\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_160'>DOB<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_3_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_161\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_161'>Name of individual and\/ or organization<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_3_161' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_162'>Address\/Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_3_162' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_163\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_163'>For the purposes:(specify)<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_3_163' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_164\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >This information includes (check all that apply):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_164'><div class='gchoice gchoice_3_164_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.1' type='checkbox'  value='Medical Records\t\t\t\t\tNeurological Evaluation'  id='choice_3_164_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_1' id='label_3_164_1' class='gform-field-label gform-field-label--type-inline'>Medical Records\t\t\t\t\tNeurological Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.2' type='checkbox'  value='Educational\/Academic Records\t\t\tBehavioral Reports'  id='choice_3_164_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_2' id='label_3_164_2' class='gform-field-label gform-field-label--type-inline'>Educational\/Academic Records\t\t\tBehavioral Reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.3' type='checkbox'  value='Psychiatric Evaluation\t\t\t\tTeacher Reports'  id='choice_3_164_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_3' id='label_3_164_3' class='gform-field-label gform-field-label--type-inline'>Psychiatric Evaluation\t\t\t\tTeacher Reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.4' type='checkbox'  value='Psychological Evaluation\t\t\t\tTreatment\/Discharge Summary'  id='choice_3_164_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_4' id='label_3_164_4' class='gform-field-label gform-field-label--type-inline'>Psychological Evaluation\t\t\t\tTreatment\/Discharge Summary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.5' type='checkbox'  value='Court Report\t\t\t\t\tSubstance Abuse Evaluation'  id='choice_3_164_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_5' id='label_3_164_5' class='gform-field-label gform-field-label--type-inline'>Court Report\t\t\t\t\tSubstance Abuse Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.6' type='checkbox'  value='An on-going exchange of information\t\tPast Services (Verbal Exchange or Reports)'  id='choice_3_164_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_6' id='label_3_164_6' class='gform-field-label gform-field-label--type-inline'>An on-going exchange of information\t\tPast Services (Verbal Exchange or Reports)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.7' type='checkbox'  value='Other (describe below)'  id='choice_3_164_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_7' id='label_3_164_7' class='gform-field-label gform-field-label--type-inline'>Other (describe below)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.8' type='checkbox'  value='Urine Screen\/Breathalyzer Results'  id='choice_3_164_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_8' id='label_3_164_8' class='gform-field-label gform-field-label--type-inline'>Urine Screen\/Breathalyzer Results<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_164_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.9' type='checkbox'  value=''  id='choice_3_164_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_164_9' id='label_3_164_9' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_165\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full authr field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_165'>This authorization is valid from<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_3_165' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_165\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_165'>Date<\/div><\/div><div id=\"field_3_166\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half authr field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_166'>to<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_3_166' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_166\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_166'>Date<\/div><\/div><div id=\"field_3_167\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >unless revoked by the undersigned.<\/div><div id=\"field_3_168\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_168'>Consent Signature(s)<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_168_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_168_valid' id='input_3_168_valid' \/><canvas id='input_3_168' width='300' height='180'><\/canvas><\/div><\/div><\/div><fieldset id=\"field_3_169\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Above Named Client<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_169'>\n                            \n                            <span id='input_3_169_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_169.3' id='input_3_169_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_169_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_170\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_170'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_170' id='input_3_170' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_170_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_170_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_170' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_172'>Parent\/Guardian\/Authorized Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_3_172' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_173\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_173'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_173' id='input_3_173' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_173_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_173_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_173' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_174\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_174'>Prepared and witnessed by<\/label><div class='ginput_container ginput_container_text'><input name='input_174' id='input_3_174' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_174\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_174'>MFS Staff Member<\/div><\/div><div id=\"field_3_175\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_175'>Revocation Signature(s)<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_175_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_175_valid' id='input_3_175_valid' \/><canvas id='input_3_175' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_176\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half authr field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_176'>I<\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_3_176' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_177\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half authr field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_177'>Revoke my consent for Multicultural Family Solutions to exchange information with the above-named individual\/organization as of this date<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_3_177' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_178\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Above Named Client<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_178'>\n                            \n                            <span id='input_3_178_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_178.3' id='input_3_178_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_178_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_179\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_179'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_179' id='input_3_179' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_179_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_179_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_179' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_180\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_180'>Parent\/Guardian\/Authorized Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_180' id='input_3_180' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_181\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_181'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_181' id='input_3_181' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_181_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_181_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_181' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_182\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_182'>Prepared and witnessed by<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_3_182' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_182\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_182'>MFS Staff Member<\/div><\/div><div id=\"field_3_183\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2).  The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2.  A general authorization for the release of medical or other information is not sufficient for this purpose.  The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.<\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='kDXHsiOnjDDEP9KorIIwHfX17ttINOABYijnmDlS\/K0jZW9yMHMQP\/VwKFS3hlggLebaKD45dga2YMUQPu1yd4QapOzH2Gv8Cl8T9fXJlNj3+78=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_3\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 3, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row woodmart_css_id=&#8221;66630321a282d&#8221; responsive_spacing=&#8221;eyJwYXJhbV90eXBlIjoid29vZG1hcnRfcmVzcG9uc2l2ZV9zcGFjaW5nIiwic2VsZWN0b3JfaWQiOiI2NjYzMDMyMWEyODJkIiwic2hvcnRjb2RlIjoidmNfcm93IiwiZGF0YSI6eyJ0YWJsZXQiOnt9LCJtb2JpbGUiOnt9fX0=&#8221; mobile_bg_img_hidden=&#8221;no&#8221; tablet_bg_img_hidden=&#8221;no&#8221; woodmart_parallax=&#8221;0&#8243; woodmart_gradient_switch=&#8221;no&#8221; woodmart_box_shadow=&#8221;no&#8221; wd_z_index=&#8221;no&#8221; woodmart_disable_overflow=&#8221;0&#8243; row_reverse_mobile=&#8221;0&#8243; row_reverse_tablet=&#8221;0&#8243;][vc_column][\/vc_column][\/vc_row][vc_row el_id=&#8221;op-tntk-rowxxx&#8221; woodmart_css_id=&#8221;6662d60740110&#8243; responsive_spacing=&#8221;eyJwYXJhbV90eXBlIjoid29vZG1hcnRfcmVzcG9uc2l2ZV9zcGFjaW5nIiwic2VsZWN0b3JfaWQiOiI2NjYyZDYwNzQwMTEwIiwic2hvcnRjb2RlIjoidmNfcm93IiwiZGF0YSI6eyJ0YWJsZXQiOnt9LCJtb2JpbGUiOnt9fX0=&#8221; mobile_bg_img_hidden=&#8221;no&#8221; tablet_bg_img_hidden=&#8221;no&#8221; woodmart_parallax=&#8221;0&#8243; woodmart_gradient_switch=&#8221;no&#8221; woodmart_box_shadow=&#8221;no&#8221;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-298","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/298","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/comments?post=298"}],"version-history":[{"count":6,"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/298\/revisions"}],"predecessor-version":[{"id":331,"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/298\/revisions\/331"}],"wp:attachment":[{"href":"https:\/\/demolinks2.com\/baffour-agyeman\/wp-json\/wp\/v2\/media?parent=298"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}