{"id":334,"date":"2026-06-03T13:57:46","date_gmt":"2026-06-03T13:57:46","guid":{"rendered":"https:\/\/demolinks2.com\/empower-mental-health\/?page_id=334"},"modified":"2026-06-03T13:58:44","modified_gmt":"2026-06-03T13:58:44","slug":"start-intake-form","status":"publish","type":"page","link":"https:\/\/demolinks2.com\/empower-mental-health\/start-intake-form\/","title":{"rendered":"Start Intake Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_section][vc_row][vc_column width=&#8221;1\/6&#8243;][\/vc_column][vc_column width=&#8221;2\/3&#8243;]\t\t<div id=\"wd-6a2032d49520e\" class=\"wd-text-block wd-wpb reset-last-child wd-rs-6a2032d49520e text-left \">\n\t\t\t<div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Adult Therapy Intake Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='334' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"e75466cf0a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/empower-mental-health\/wp-json\/wp\/v2\/pages\/334\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Client Information<\/strong><\/h2><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_names_first_name_' id='label_ff_4_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_4_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_names_last_name_' id='label_ff_4_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_4_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime' id='label_ff_4_datetime' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_4_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text' id='label_ff_4_input_text' aria-label=\"Preferred Name:\">Preferred Name: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_4_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_1' id='label_ff_4_input_text_1' aria-label=\"Pronouns:\">Pronouns: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_4_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_address_1_address_line_1_' id='label_ff_4_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_4_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_address_1_city_' id='label_ff_4_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_4_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_address_1_state_' id='label_ff_4_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_4_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_address_1_zip_' id='label_ff_4_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_4_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_phone' id='label_ff_4_phone' aria-label=\"Phone Number:\">Phone Number: <\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone\" id=\"ff_4_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_email' id='label_ff_4_email' aria-label=\"Email Address:\">Email Address: <\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_4_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Preferred Method of Contact:\">Preferred Method of Contact:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_23e11f89711ac07609cebfe5dd66b23a'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Phone\"  id='checkbox_23e11f89711ac07609cebfe5dd66b23a' aria-label='Phone' aria-invalid='false' aria-required=false> <span>Phone<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1a1774bc8186cefbe0b5bdaa1371c0e3'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Text \"  id='checkbox_1a1774bc8186cefbe0b5bdaa1371c0e3' aria-label='Text' aria-invalid='false' aria-required=false> <span>Text <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_e635c246a746e2ffa72c0fb55dbb20a8'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Email \"  id='checkbox_e635c246a746e2ffa72c0fb55dbb20a8' aria-label='Email' aria-invalid='false' aria-required=false> <span>Email <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_781d04bb309e86c9540bbc8f74569277'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Patient Portal\"  id='checkbox_781d04bb309e86c9540bbc8f74569277' aria-label='Patient Portal' aria-invalid='false' aria-required=false> <span>Patient Portal<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_2\" ><h3><strong>Emergency Contact<\/strong><\/h3><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_2' id='label_ff_4_input_text_2' aria-label=\"Name:\">Name: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_4_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_3' id='label_ff_4_input_text_3' aria-label=\"Relationship:\">Relationship: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_4_input_text_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_phone_1' id='label_ff_4_phone_1' aria-label=\"Phone Number:\">Phone Number: <\/label><\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone_1\" id=\"ff_4_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Insurance Information<\/strong><\/h2><\/div><hr \/><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_4' id='label_ff_4_input_text_4' aria-label=\"Primary Insurance Company:\">Primary Insurance Company: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_4_input_text_4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_numeric_field' id='label_ff_4_numeric_field' aria-label=\"Member ID Number:\">Member ID Number: <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_4_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_numeric_field_1' id='label_ff_4_numeric_field_1' aria-label=\"Group Number:\">Group Number: <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_1\" id=\"ff_4_numeric_field_1\" class=\"ff-el-form-control\" data-name=\"numeric_field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_5' id='label_ff_4_input_text_5' aria-label=\"Policy Holder Name:\">Policy Holder Name: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_4_input_text_5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_1' id='label_ff_4_datetime_1' aria-label=\"Policy Holder Date of Birth:\">Policy Holder Date of Birth: <\/label><\/div><div class='ff-el-input--content'><input  aria-label='Policy Holder Date of Birth:  Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_1\" id=\"ff_4_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Relationship to Policy Holder:\">Relationship to Policy Holder:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_a0779f7ecc6f2e36654a5064db94b041'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self\"  id='input_radio_a0779f7ecc6f2e36654a5064db94b041' aria-label='Self' aria-invalid='false' aria-required=false> <span>Self<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_752f4256643c4fb6ead7d49d0e3b922a'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Spouse\"  id='input_radio_752f4256643c4fb6ead7d49d0e3b922a' aria-label='Spouse' aria-invalid='false' aria-required=false> <span>Spouse<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6f3d271f3ca241a11349894156fbbafd'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Parent \"  id='input_radio_6f3d271f3ca241a11349894156fbbafd' aria-label='Parent' aria-invalid='false' aria-required=false> <span>Parent <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_a648ac8ad10b3be9608651a76ba8c588'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other: \"  id='input_radio_a648ac8ad10b3be9608651a76ba8c588' aria-label='Other:' aria-invalid='false' aria-required=false> <span>Other: <\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_4\" ><h3><strong>Secondary Insurance (if applicable):<\/strong><\/h3><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_6' id='label_ff_4_input_text_6' aria-label=\"Insurance Company:\">Insurance Company: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_4_input_text_6\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_numeric_field_3' id='label_ff_4_numeric_field_3' aria-label=\"Member ID Number:\">Member ID Number: <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_3\" id=\"ff_4_numeric_field_3\" class=\"ff-el-form-control\" data-name=\"numeric_field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_numeric_field_2' id='label_ff_4_numeric_field_2' aria-label=\"Group Number:\">Group Number: <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_2\" id=\"ff_4_numeric_field_2\" class=\"ff-el-form-control\" data-name=\"numeric_field_2\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_7' id='label_ff_4_input_text_7' aria-label=\"Policy Holder Name:\">Policy Holder Name: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_4_input_text_7\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_8' id='label_ff_4_input_text_8' aria-label=\"Relationship to Policy Holder:\">Relationship to Policy Holder:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_4_input_text_8\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_5\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Financial Responsibility &amp; Payment Information<\/strong><\/h2><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Payment Method on File:\">Payment Method on File:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_5c0fad76d2a3797e9971174e6d55a593'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Credit Card\"  id='input_radio_1_5c0fad76d2a3797e9971174e6d55a593' aria-label='Credit Card' aria-invalid='false' aria-required=false> <span>Credit Card<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_dc941fd80e9ee14bef0a5480f2ccde1a'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Debit Card\"  id='input_radio_1_dc941fd80e9ee14bef0a5480f2ccde1a' aria-label='Debit Card' aria-invalid='false' aria-required=false> <span>Debit Card<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_32e4b05ea410376207c06c8c421a1ba0'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"HSA\/FSA\"  id='input_radio_1_32e4b05ea410376207c06c8c421a1ba0' aria-label='HSA\/FSA' aria-invalid='false' aria-required=false> <span>HSA\/FSA<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_bf6baf2c782c91bd27d7a25a02092866'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_1_bf6baf2c782c91bd27d7a25a02092866' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_9' id='label_ff_4_input_text_9' aria-label=\"Other:\">Other:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_4_input_text_9\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_6\" ><h4><strong>Financial Agreement<\/strong><\/h4>\n<p>Please initial each statement:<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that I am responsible for all copays, coinsurance, deductibles, and any non-covered services.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_6198cac96f9bad5eec1564e133fd8957><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement\" id=\"gdpr-agreement_6198cac96f9bad5eec1564e133fd8957\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that I am responsible for all copays, coinsurance, deductibles, and any non-covered services.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that insurance verification is not a guarantee of payment.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_1_727b8144125079c9f68671b290f3889f><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_1\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_1\" id=\"gdpr-agreement_1_727b8144125079c9f68671b290f3889f\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that insurance verification is not a guarantee of payment.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that I am responsible for payment of services denied by my insurance carrier.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_2_e6e235631309ad50faf4b2f325294254><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_2\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_2\" id=\"gdpr-agreement_2_e6e235631309ad50faf4b2f325294254\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that I am responsible for payment of services denied by my insurance carrier.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I authorize my therapist to bill my insurance company on my behalf.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_3_f86a660ccbdea3f9006b795223a4f70a><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_3\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_3\" id=\"gdpr-agreement_3_f86a660ccbdea3f9006b795223a4f70a\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I authorize my therapist to bill my insurance company on my behalf.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I authorize payment of insurance benefits directly to the provider.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_4_4f19f7af270123ed42e7d0009c7b3b8c><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_4\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_4\" id=\"gdpr-agreement_4_4f19f7af270123ed42e7d0009c7b3b8c\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I authorize payment of insurance benefits directly to the provider.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that balances not covered by insurance are my responsibility' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_5_a774d786d7a5d68d4cc53ffe5f34612a><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_5\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_5\" id=\"gdpr-agreement_5_a774d786d7a5d68d4cc53ffe5f34612a\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that balances not covered by insurance are my responsibility<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that payment is due at the time services are rendered unless other arrangements have been made.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_6_4b7f2717c0c9fde249949c29d19c7ac0><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_6\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_6\" id=\"gdpr-agreement_6_4b7f2717c0c9fde249949c29d19c7ac0\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that payment is due at the time services are rendered unless other arrangements have been made.<\/div><\/label><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_7\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Appointment Policies<\/strong><\/h2><\/div><hr \/><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_8\" ><h4><strong>Cancellation &amp; No-Show Policy<\/strong><\/h4>\n<p>Please initial:<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that appointments canceled with less than 24 hours notice may be subject to a cancellation fee of $ 75.00.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_7_df897367dd8801a4f66f0fc597b93ccf><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_7\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_7\" id=\"gdpr-agreement_7_df897367dd8801a4f66f0fc597b93ccf\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that appointments canceled with less than 24 hours notice may be subject to a cancellation fee of $ 75.00.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that missed appointments (no-shows) may be charged a fee of $100.00.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_8_eeb808ad0c85dce63b66ba2d2f8b7f88><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_8\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_8\" id=\"gdpr-agreement_8_eeb808ad0c85dce63b66ba2d2f8b7f88\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that missed appointments (no-shows) may be charged a fee of $100.00.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that insurance companies generally do not cover missed appointment fees.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_9_0149f44fa47a14169d2b7e9f682dc256><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_9\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_9\" id=\"gdpr-agreement_9_0149f44fa47a14169d2b7e9f682dc256\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that insurance companies generally do not cover missed appointment fees.<\/div><\/label><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_9\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Presenting Concerns<\/strong><\/h2><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description' id='label_ff_4_description' aria-label=\"What brings you to therapy at this time?\">What brings you to therapy at this time?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description\" name=\"description\" id=\"ff_4_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_10' id='label_ff_4_input_text_10' aria-label=\"How long have you been experiencing these concerns?\">How long have you been experiencing these concerns?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_4_input_text_10\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_1' id='label_ff_4_description_1' aria-label=\"What are your goals for therapy?\">What are your goals for therapy?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_1\" name=\"description_1\" id=\"ff_4_description_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_10\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Mental Health History<\/strong><\/h2><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you previously participated in therapy?\">Have you previously participated in therapy?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_d87cacf9a91e9ff707fb904da5cb441f'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_2_d87cacf9a91e9ff707fb904da5cb441f' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_987078253f2991bd99d0104ad4898b39'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_2_987078253f2991bd99d0104ad4898b39' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_11' id='label_ff_4_input_text_11' aria-label=\"Provider Name:\">Provider Name: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" data-name=\"input_text_11\" id=\"ff_4_input_text_11\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_2' id='label_ff_4_datetime_2' aria-label=\"Dates of Treatment:\">Dates of Treatment: <\/label><\/div><div class='ff-el-input--content'><input  aria-label='Dates of Treatment:  Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_4_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_12' id='label_ff_4_input_text_12' aria-label=\"Reason for Treatment:\">Reason for Treatment:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_4_input_text_12\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you ever been hospitalized for mental health concerns?\">Have you ever been hospitalized for mental health concerns?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_0c24a7fe17eeea539f59272c9aa14549'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_3_0c24a7fe17eeea539f59272c9aa14549' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_a59ecab19fc0be025698eb3166ebebe2'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3_a59ecab19fc0be025698eb3166ebebe2' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_2' id='label_ff_4_description_2' aria-label=\"If yes, please explain:\">If yes, please explain:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_2\" name=\"description_2\" id=\"ff_4_description_2\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_11\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Current Symptoms<\/strong><\/h2><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Please check any symptoms you have experienced recently:\">Please check any symptoms you have experienced recently:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_52fb8b9311fe5e5c7821afc44591f4ac'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Anxiety\"  id='input_radio_4_52fb8b9311fe5e5c7821afc44591f4ac' aria-label='Anxiety' aria-invalid='false' aria-required=false> <span>Anxiety<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_210bdc638cbeb09f241ed6f53dbf6383'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Excessive Worry\"  id='input_radio_4_210bdc638cbeb09f241ed6f53dbf6383' aria-label='Excessive Worry' aria-invalid='false' aria-required=false> <span>Excessive Worry<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_92798807fda993c130c7ab7e11c14d50'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Panic Attacks\"  id='input_radio_4_92798807fda993c130c7ab7e11c14d50' aria-label='Panic Attacks' aria-invalid='false' aria-required=false> <span>Panic Attacks<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_9efd6db926d2acc5117bdafa68d38e79'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Depression\"  id='input_radio_4_9efd6db926d2acc5117bdafa68d38e79' aria-label='Depression' aria-invalid='false' aria-required=false> <span>Depression<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_391406703aa414db9b700c4b8c6e704d'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Sadness\"  id='input_radio_4_391406703aa414db9b700c4b8c6e704d' aria-label='Sadness' aria-invalid='false' aria-required=false> <span>Sadness<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_963b18c492df3fe7cc00fd28288b4cba'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Irritability\"  id='input_radio_4_963b18c492df3fe7cc00fd28288b4cba' aria-label='Irritability' aria-invalid='false' aria-required=false> <span>Irritability<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_a8708a6a2778cee3d392581f4dbfc341'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mood Swings\"  id='input_radio_4_a8708a6a2778cee3d392581f4dbfc341' aria-label='Mood Swings' aria-invalid='false' aria-required=false> <span>Mood Swings<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_0505b639c6352d8d853455721ae51998'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Difficulty Sleeping\"  id='input_radio_4_0505b639c6352d8d853455721ae51998' aria-label='Difficulty Sleeping' aria-invalid='false' aria-required=false> <span>Difficulty Sleeping<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_14c93f63c475557d773fd04006eb5bab'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Fatigue\"  id='input_radio_4_14c93f63c475557d773fd04006eb5bab' aria-label='Fatigue' aria-invalid='false' aria-required=false> <span>Fatigue<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_3d234e73dcaa37ead6769aa957d37e78'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Difficulty Concentrating\"  id='input_radio_4_3d234e73dcaa37ead6769aa957d37e78' aria-label='Difficulty Concentrating' aria-invalid='false' aria-required=false> <span>Difficulty Concentrating<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_134c80b2b825d6a3bbb90b398c95e9ba'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Racing Thoughts\"  id='input_radio_4_134c80b2b825d6a3bbb90b398c95e9ba' aria-label='Racing Thoughts' aria-invalid='false' aria-required=false> <span>Racing Thoughts<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_dbdcd427b935b63a2ac77adb56b046c7'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Low Motivation\"  id='input_radio_4_dbdcd427b935b63a2ac77adb56b046c7' aria-label='Low Motivation' aria-invalid='false' aria-required=false> <span>Low Motivation<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_587264c88a625cea8583d19c9201dd89'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Grief\/Loss\"  id='input_radio_4_587264c88a625cea8583d19c9201dd89' aria-label='Grief\/Loss' aria-invalid='false' aria-required=false> <span>Grief\/Loss<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_8154251f47486b67821200bb9c2e7c42'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Relationship Problems\"  id='input_radio_4_8154251f47486b67821200bb9c2e7c42' aria-label='Relationship Problems' aria-invalid='false' aria-required=false> <span>Relationship Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_035130e795fc1045262014307d0e2c18'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Work\/School Stress\"  id='input_radio_4_035130e795fc1045262014307d0e2c18' aria-label='Work\/School Stress' aria-invalid='false' aria-required=false> <span>Work\/School Stress<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_ca6dc74cd31e80b9e3e19af55afbfaa1'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Trauma History\"  id='input_radio_4_ca6dc74cd31e80b9e3e19af55afbfaa1' aria-label='Trauma History' aria-invalid='false' aria-required=false> <span>Trauma History<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_a5305d973f1b27904a820baaf3a00f36'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Anger\"  id='input_radio_4_a5305d973f1b27904a820baaf3a00f36' aria-label='Anger' aria-invalid='false' aria-required=false> <span>Anger<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_3f386bd00bd7a1a8f049bbb97f4462b6'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Social Withdrawal\"  id='input_radio_4_3f386bd00bd7a1a8f049bbb97f4462b6' aria-label='Social Withdrawal' aria-invalid='false' aria-required=false> <span>Social Withdrawal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_68f060d866697f93d9f8f26edd1b67ef'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_4_68f060d866697f93d9f8f26edd1b67ef' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_13' id='label_ff_4_input_text_13' aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_4_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_12\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Medical History<\/strong><\/h2><\/div><hr \/><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_14' id='label_ff_4_input_text_14' aria-label=\"Primary Care Physician:\">Primary Care Physician: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" data-name=\"input_text_14\" id=\"ff_4_input_text_14\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_3' id='label_ff_4_datetime_3' aria-label=\"Date of Last Physical Exam:\">Date of Last Physical Exam: <\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Last Physical Exam:  Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_3\" id=\"ff_4_datetime_3\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_3\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_3' id='label_ff_4_description_3' aria-label=\"Current Medical Conditions:\">Current Medical Conditions:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_3\" name=\"description_3\" id=\"ff_4_description_3\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_3\" ><\/textarea><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_15' id='label_ff_4_input_text_15' aria-label=\"Current Medications:\">Current Medications:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_15\" class=\"ff-el-form-control\" data-name=\"input_text_15\" id=\"ff_4_input_text_15\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_16' id='label_ff_4_input_text_16' aria-label=\"Medication Dosage\tPrescribing Provider\">Medication Dosage\tPrescribing Provider<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_16\" class=\"ff-el-form-control\" data-name=\"input_text_16\" id=\"ff_4_input_text_16\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_4' id='label_ff_4_description_4' aria-label=\"Allergies:\">Allergies:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_4\" name=\"description_4\" id=\"ff_4_description_4\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_4\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_13\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Substance Use<\/strong><\/h2>\n<p>Do you currently use any of the following?<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_4 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Alcohol\">Alcohol<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_569d5af0f7670275a4fb2668e83b749b'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Never\"  id='input_radio_5_569d5af0f7670275a4fb2668e83b749b' aria-label='Never' aria-invalid='false' aria-required=false> <span>Never<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_a1b13644dd9ddd29e4b0027c42cb002a'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Occasionally\"  id='input_radio_5_a1b13644dd9ddd29e4b0027c42cb002a' aria-label='Occasionally' aria-invalid='false' aria-required=false> <span>Occasionally<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_2489bf748410ebc2be6b3ad28256c4dc'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Weekly\"  id='input_radio_5_2489bf748410ebc2be6b3ad28256c4dc' aria-label='Weekly' aria-invalid='false' aria-required=false> <span>Weekly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_e196335b16ed2618aeb1683d88e9c951'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Daily\"  id='input_radio_5_e196335b16ed2618aeb1683d88e9c951' aria-label='Daily' aria-invalid='false' aria-required=false> <span>Daily<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Tobacco\/Nicotine\">Tobacco\/Nicotine<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_1aca7b463d35b722b0d8beffe74b2ae7'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Never\"  id='input_radio_6_1aca7b463d35b722b0d8beffe74b2ae7' aria-label='Never' aria-invalid='false' aria-required=false> <span>Never<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_26c0beaca4f97001d82ea971fd32a460'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Occasionally\"  id='input_radio_6_26c0beaca4f97001d82ea971fd32a460' aria-label='Occasionally' aria-invalid='false' aria-required=false> <span>Occasionally<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_4fcdd89e94620124a93e38d79a21a2e3'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Daily\"  id='input_radio_6_4fcdd89e94620124a93e38d79a21a2e3' aria-label='Daily' aria-invalid='false' aria-required=false> <span>Daily<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Marijuana\">Marijuana<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_5106707bad31cbbe2267f46ea1e4fa7b'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Never\"  id='input_radio_7_5106707bad31cbbe2267f46ea1e4fa7b' aria-label='Never' aria-invalid='false' aria-required=false> <span>Never<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_913edbc5dcb1fa4a4fb8823d4edfc733'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Occasionally\"  id='input_radio_7_913edbc5dcb1fa4a4fb8823d4edfc733' aria-label='Occasionally' aria-invalid='false' aria-required=false> <span>Occasionally<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_a8683ccb0e2fc7c0f0633e75435171ff'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Weekly\"  id='input_radio_7_a8683ccb0e2fc7c0f0633e75435171ff' aria-label='Weekly' aria-invalid='false' aria-required=false> <span>Weekly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_4ec952e6040cbe86414848d4fcdf61ca'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Daily\"  id='input_radio_7_4ec952e6040cbe86414848d4fcdf61ca' aria-label='Daily' aria-invalid='false' aria-required=false> <span>Daily<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other Substances\">Other Substances<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_ba9670fb403c7a35eda6b2f8fb8694b1'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='input_radio_8_ba9670fb403c7a35eda6b2f8fb8694b1' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_806fc98c53cd7ebf8e7f159e9043d930'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_8_806fc98c53cd7ebf8e7f159e9043d930' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_17' id='label_ff_4_input_text_17' aria-label=\"If Yes (Please explain)\">If Yes (Please explain)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_17\" class=\"ff-el-form-control\" data-name=\"input_text_17\" id=\"ff_4_input_text_17\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_14\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Family &amp; Social History<\/strong><\/h2><\/div><hr \/><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Relationship Status:\">Relationship Status:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_144d201387866b5b732d1365b94eaebe'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Single\"  id='input_radio_9_144d201387866b5b732d1365b94eaebe' aria-label='Single' aria-invalid='false' aria-required=false> <span>Single<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_b109081c6b90c0596e447d7d60367e48'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Married\"  id='input_radio_9_b109081c6b90c0596e447d7d60367e48' aria-label='Married' aria-invalid='false' aria-required=false> <span>Married<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_dc069f1a1c5a7ec580cf30cc738417d3'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Divorced\"  id='input_radio_9_dc069f1a1c5a7ec580cf30cc738417d3' aria-label='Divorced' aria-invalid='false' aria-required=false> <span>Divorced<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_962eb41b20dd322fd49554d2263b0306'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Separated\"  id='input_radio_9_962eb41b20dd322fd49554d2263b0306' aria-label='Separated' aria-invalid='false' aria-required=false> <span>Separated<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_1034f9e5ee98a245d322736acbc9beaa'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Partnered\"  id='input_radio_9_1034f9e5ee98a245d322736acbc9beaa' aria-label='Partnered' aria-invalid='false' aria-required=false> <span>Partnered<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_c329ba17d735990aa02fb753d6dc3530'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Widowed\"  id='input_radio_9_c329ba17d735990aa02fb753d6dc3530' aria-label='Widowed' aria-invalid='false' aria-required=false> <span>Widowed<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you have children?\">Do you have children?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_bd5ae81724bb68f39afb17d5b04189c9'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_10_bd5ae81724bb68f39afb17d5b04189c9' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_f176c22167254a5bc8e018f7857b98bb'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_10_f176c22167254a5bc8e018f7857b98bb' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_18' id='label_ff_4_input_text_18' aria-label=\"If yes, ages:\">If yes, ages: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_18\" class=\"ff-el-form-control\" data-name=\"input_text_18\" id=\"ff_4_input_text_18\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_19' id='label_ff_4_input_text_19' aria-label=\"Who lives in your household?\">Who lives in your household?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_19\" class=\"ff-el-form-control\" data-name=\"input_text_19\" id=\"ff_4_input_text_19\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_5' id='label_ff_4_description_5' aria-label=\"Describe your support system:\">Describe your support system:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_5\" name=\"description_5\" id=\"ff_4_description_5\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_5\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_15\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Employment &amp; Education<\/strong><\/h2><\/div><hr \/><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Current Employment Status:\">Current Employment Status:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_a22838ffdaf3cfbeaace59413f81f3f1'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Full-Time\"  id='input_radio_11_a22838ffdaf3cfbeaace59413f81f3f1' aria-label='Full-Time' aria-invalid='false' aria-required=false> <span>Full-Time<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_0f46772d9f2c9b2508249bffb25a68d3'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Part-Time\"  id='input_radio_11_0f46772d9f2c9b2508249bffb25a68d3' aria-label='Part-Time' aria-invalid='false' aria-required=false> <span>Part-Time<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_40f6725c2019185731df12f4695b7711'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self-Employed\"  id='input_radio_11_40f6725c2019185731df12f4695b7711' aria-label='Self-Employed' aria-invalid='false' aria-required=false> <span>Self-Employed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_b3cab8f1c2768b074eb5677e2e798736'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Unemployed\"  id='input_radio_11_b3cab8f1c2768b074eb5677e2e798736' aria-label='Unemployed' aria-invalid='false' aria-required=false> <span>Unemployed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_ca7a33de2ea77e02e50b2c5b3d5b8ce4'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Student\"  id='input_radio_11_ca7a33de2ea77e02e50b2c5b3d5b8ce4' aria-label='Student' aria-invalid='false' aria-required=false> <span>Student<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_42a6be78aaae67c5bea06ada130e287b'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Retired\"  id='input_radio_11_42a6be78aaae67c5bea06ada130e287b' aria-label='Retired' aria-invalid='false' aria-required=false> <span>Retired<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_20' id='label_ff_4_input_text_20' aria-label=\"Occupation:\">Occupation:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_20\" class=\"ff-el-form-control\" data-name=\"input_text_20\" id=\"ff_4_input_text_20\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Highest Level of Education:\">Highest Level of Education:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_ca1b36c0babc6842aced93842fbbf1aa'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"High School\"  id='input_radio_12_ca1b36c0babc6842aced93842fbbf1aa' aria-label='High School' aria-invalid='false' aria-required=false> <span>High School<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_9e2efd2296dd8e0af50a4228784d0230'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Some College\"  id='input_radio_12_9e2efd2296dd8e0af50a4228784d0230' aria-label='Some College' aria-invalid='false' aria-required=false> <span>Some College<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_93dd5da1838d3ababd69584452c65525'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Associate Degree\"  id='input_radio_12_93dd5da1838d3ababd69584452c65525' aria-label='Associate Degree' aria-invalid='false' aria-required=false> <span>Associate Degree<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_0c92df6090a432812d8eb1230aa7cdb4'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Bachelor&#039;s Degree\"  id='input_radio_12_0c92df6090a432812d8eb1230aa7cdb4' aria-label='Bachelor&#039;s Degree' aria-invalid='false' aria-required=false> <span>Bachelor's Degree<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_ed20b104ab28ce0260864ada939c7cc3'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Master&#039;s Degree\"  id='input_radio_12_ed20b104ab28ce0260864ada939c7cc3' aria-label='Master&#039;s Degree' aria-invalid='false' aria-required=false> <span>Master's Degree<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_1f2c9c91cf977dd51cda5819b65ed949'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Doctorate\"  id='input_radio_12_1f2c9c91cf977dd51cda5819b65ed949' aria-label='Doctorate' aria-invalid='false' aria-required=false> <span>Doctorate<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_4995b70f4f0c51118861904142f4fc66'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_12_4995b70f4f0c51118861904142f4fc66' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_21' id='label_ff_4_input_text_21' aria-label=\"Other:\">Other:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_21\" class=\"ff-el-form-control\" data-name=\"input_text_21\" id=\"ff_4_input_text_21\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_16\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Risk Assessment<\/strong><\/h2><\/div><hr \/><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you ever had thoughts of harming yourself?\">Have you ever had thoughts of harming yourself?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_02fc7b3e42812b000de75b39227b7fd2'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_13_02fc7b3e42812b000de75b39227b7fd2' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_6273970bb6fdab8bc122cda8e02c81d4'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_13_6273970bb6fdab8bc122cda8e02c81d4' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_22' id='label_ff_4_input_text_22' aria-label=\"If yes, please explain:\">If yes, please explain:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_22\" class=\"ff-el-form-control\" data-name=\"input_text_22\" id=\"ff_4_input_text_22\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you ever attempted suicide?\">Have you ever attempted suicide?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_a268e730efbac95891044cc0fcb2b837'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_14_a268e730efbac95891044cc0fcb2b837' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_abd6e7078eaa2f93ac6dafb3538995f8'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_14_abd6e7078eaa2f93ac6dafb3538995f8' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_23' id='label_ff_4_input_text_23' aria-label=\"If yes, please explain:\">If yes, please explain:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_23\" class=\"ff-el-form-control\" data-name=\"input_text_23\" id=\"ff_4_input_text_23\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you currently have thoughts of harming yourself?\">Do you currently have thoughts of harming yourself?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_1bd50e6fb52250239c63b2732ec5ad48'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_15_1bd50e6fb52250239c63b2732ec5ad48' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_35e69c0f3cfbc319dab6589dcd7c92e8'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_15_35e69c0f3cfbc319dab6589dcd7c92e8' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you currently have thoughts of harming someone else?\">Do you currently have thoughts of harming someone else?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_16_5b268b8244469b21031f83f4b932cad7'><input  type=\"radio\" name=\"input_radio_16\" data-name=\"input_radio_16\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_16_5b268b8244469b21031f83f4b932cad7' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_16_b26466ba59b9bc949737c97de6942972'><input  type=\"radio\" name=\"input_radio_16\" data-name=\"input_radio_16\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_16_b26466ba59b9bc949737c97de6942972' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_24' id='label_ff_4_input_text_24' aria-label=\"If yes to either question, please explain:\">If yes to either question, please explain:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_24\" class=\"ff-el-form-control\" data-name=\"input_text_24\" id=\"ff_4_input_text_24\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_17\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Telehealth Consent<\/strong><\/h2><\/div><hr \/><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand the benefits and risks associated with telehealth services.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_10_6398446f4e0cb728b441bb3601bfe8b4><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_10\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_10\" id=\"gdpr-agreement_10_6398446f4e0cb728b441bb3601bfe8b4\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand the benefits and risks associated with telehealth services.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that confidentiality protections remain in place during telehealth sessions.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_11_0dd26bf82be725ae23b4e567347398cb><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_11\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_11\" id=\"gdpr-agreement_11_0dd26bf82be725ae23b4e567347398cb\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that confidentiality protections remain in place during telehealth sessions.<\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that technical difficulties may interrupt services.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_12_0a4bc12ae282f50c491121092987a7a0><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_12\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_12\" id=\"gdpr-agreement_12_0a4bc12ae282f50c491121092987a7a0\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand that technical difficulties may interrupt services.<\/div><\/label><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_18\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>Consent for Treatment<\/strong><\/h2>\n<p>I voluntarily consent to participate in psychotherapy services. I understand the nature and purpose of treatment, confidentiality limitations, and my rights as a client.<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Client Signature:\">Client Signature: <\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_4' \n            class='fluentform-signature-pad' \n            data-form-id='4'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Sign Here<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_4' id='label_ff_4_datetime_4' aria-label=\"Date:\">Date: <\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date:  Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_4\" id=\"ff_4_datetime_4\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_4\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Therapist Signature:\">Therapist Signature:<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_1' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_1_4' \n            class='fluentform-signature-pad' \n            data-form-id='4'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Sign Here<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_5' id='label_ff_4_datetime_5' aria-label=\"Date:\">Date: <\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date:  Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_5\" id=\"ff_4_datetime_5\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_5\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_19\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h2><strong>HIPAA Acknowledgment<\/strong><\/h2>\n<p>I acknowledge that I have received and\/or been offered a copy of the Notice of Privacy Practices.<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Client Signature:\">Client Signature: <\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_2' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_2_4' \n            class='fluentform-signature-pad' \n            data-form-id='4'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Sign Here<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_6' id='label_ff_4_datetime_6' aria-label=\"Date:\">Date:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_6\" id=\"ff_4_datetime_6\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_6\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_20\" ><h4><strong>Availability for Therapy Services<\/strong><\/h4>\n<p>Please indicate your preferred days and times for scheduling appointments.<\/p><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Days Available\">Days Available<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_af6c4f3005c3c0641aa2e64d98c8ba3e'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Monday\"  id='input_radio_17_af6c4f3005c3c0641aa2e64d98c8ba3e' aria-label='Monday' aria-invalid='false' aria-required=false> <span>Monday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_7d3aaa5b8046f73c0bd81063329056c3'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Tuesday\"  id='input_radio_17_7d3aaa5b8046f73c0bd81063329056c3' aria-label='Tuesday' aria-invalid='false' aria-required=false> <span>Tuesday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_710f27d88cbf6f19294e03fa39ac1899'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Wednesday\"  id='input_radio_17_710f27d88cbf6f19294e03fa39ac1899' aria-label='Wednesday' aria-invalid='false' aria-required=false> <span>Wednesday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_50be3effc19bd31fa6aa47254cb9385b'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Thursday\"  id='input_radio_17_50be3effc19bd31fa6aa47254cb9385b' aria-label='Thursday' aria-invalid='false' aria-required=false> <span>Thursday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_637a99016812f53506916d17fbeb3ee9'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Friday\"  id='input_radio_17_637a99016812f53506916d17fbeb3ee9' aria-label='Friday' aria-invalid='false' aria-required=false> <span>Friday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_d30edf2a83c9a95b92f6d4adefe43f8f'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Saturday (if available)\"  id='input_radio_17_d30edf2a83c9a95b92f6d4adefe43f8f' aria-label='Saturday (if available)' aria-invalid='false' aria-required=false> <span>Saturday (if available)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_32de1f4b9347fbab8bb9218d3d351bbb'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Sunday (if available)\"  id='input_radio_17_32de1f4b9347fbab8bb9218d3d351bbb' aria-label='Sunday (if available)' aria-invalid='false' aria-required=false> <span>Sunday (if available)<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Preferred Appointment Times\">Preferred Appointment Times<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_a4233b588eda52a5cfcfd6cdd47fddb8'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"00 AM \u2013 12\"  id='checkbox_1_a4233b588eda52a5cfcfd6cdd47fddb8' aria-label='Morning (8' aria-invalid='false' aria-required=false> <span>Morning (8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_f0c8183a8750f82e7de85e884dc5d4bd'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"00 PM \u2013 5\"  id='checkbox_1_f0c8183a8750f82e7de85e884dc5d4bd' aria-label='Afternoon (12' aria-invalid='false' aria-required=false> <span>Afternoon (12<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_26b9ba4cc2a60fcff77b759c559b039e'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"00 PM \u2013 8\"  id='checkbox_1_26b9ba4cc2a60fcff77b759c559b039e' aria-label='Evening (5' aria-invalid='false' aria-required=false> <span>Evening (5<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_21\" ><h4><strong>Specific Availability<\/strong><\/h4>\n<p>Please list the days and times you are generally available for appointments:<\/p><\/div>        <div class=\"ff-repeater-container ff-el-repeater  ff_columns_total_2  \" data-name=\"ff_cn_id_20\" data-root_name=\"repeater_container\" >\n            <div class='ff-el-input--label asterisk-right'><label aria-label='Specific Availability' for=''>Specific Availability<\/label><\/div>            <div class='ff-el-input--content'>\n                <div role=\"list\" aria-label=\"\" data-max_repeat=\"\" data-root_name=\"repeater_container\" class=\"ff_repeater_container_list ff_flexible_list\">\n                    <div class=\"ff_repeater_body\" role=\"rowgroup\">\n                        <div class=\"ff_repeater_cont_row\" role=\"row\">\n                            <div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'>\n                <div class=\"ff_repeater_cell\" role=\"cell\">\n<!--                    <div class=\"--><!--\">-->\n<!--                        <label for=\"--><!--\">-->\n<!--                            --><!--                        <\/label>-->\n<!--                    <\/div>-->\n            \n                    <div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_repeater_container_0' id='label_ff_4_repeater_container_0' aria-label=\"Day\">Day<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"repeater_container[0][0]\" class=\"ff-el-form-control\" data-name=\"repeater_container_0_0\" aria-label=\"repeater level 1 and field Day\" id=\"ff_4_repeater_container_0\" data-repeater_index=\"0\" data-type=\"repeater_container\" data-error_index=\"repeater_container[0]\"  aria-invalid=\"false\" aria-required=false><\/div><\/div>                <\/div>\n                <\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'>\n                <div class=\"ff_repeater_cell\" role=\"cell\">\n<!--                    <div class=\"--><!--\">-->\n<!--                        <label for=\"--><!--\">-->\n<!--                            --><!--                        <\/label>-->\n<!--                    <\/div>-->\n            \n                    <div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_repeater_container_1' id='label_ff_4_repeater_container_1' aria-label=\"Time\">Time<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"repeater_container[0][1]\" class=\"ff-el-form-control\" data-name=\"repeater_container_1_0\" aria-label=\"repeater level 1 and field Time\" id=\"ff_4_repeater_container_1\" data-repeater_index=\"1\" data-type=\"repeater_container\" data-error_index=\"repeater_container[1]\"  aria-invalid=\"false\" aria-required=false><\/div><\/div>                <\/div>\n                <\/div><div class='ff_repeater_cell repeat_btn' role='cell' style='flex-basis: 0%;'><div class=\"ff-el-repeat-buttons-list js-container-repeat-buttons\"><span role=\"button\" aria-label=\"add repeater\" class=\"repeat-plus\"><svg tabindex=\"0\" width=\"20\" height=\"20\" viewBox=\"0 0 512 512\"><path d=\"m256 48c-115 0-208 93-208 208 0 115 93 208 208 208 115 0 208-93 208-208 0-115-93-208-208-208z m107 229l-86 0 0 86-42 0 0-86-86 0 0-42 86 0 0-86 42 0 0 86 86 0z\"><\/path><\/svg><\/span><span role=\"button\" aria-label=\"remove repeater\" class=\"repeat-minus\"><svg tabindex=\"0\" width=\"20\" height=\"20\" viewBox=\"0 0 512 512\"><path d=\"m256 48c-115 0-208 93-208 208 0 115 93 208 208 208 115 0 208-93 208-208 0-115-93-208-208-208z m107 229l-214 0 0-42 214 0z\"\"><\/path><\/svg><\/span><\/div><\/div>                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n        <div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Frequency Preference\">Frequency Preference<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18_8f079abf98a26f6c5c8d675fd228a8c8'><input  type=\"radio\" name=\"input_radio_18\" data-name=\"input_radio_18\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Weekly\"  id='input_radio_18_8f079abf98a26f6c5c8d675fd228a8c8' aria-label='Weekly' aria-invalid='false' aria-required=false> <span>Weekly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18_d666fb2757bf886691e773ce7aaef00d'><input  type=\"radio\" name=\"input_radio_18\" data-name=\"input_radio_18\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Bi-Weekly\"  id='input_radio_18_d666fb2757bf886691e773ce7aaef00d' aria-label='Bi-Weekly' aria-invalid='false' aria-required=false> <span>Bi-Weekly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18_ce909d53b72941106eb9ae828ddf049f'><input  type=\"radio\" name=\"input_radio_18\" data-name=\"input_radio_18\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Monthly\"  id='input_radio_18_ce909d53b72941106eb9ae828ddf049f' aria-label='Monthly' aria-invalid='false' aria-required=false> <span>Monthly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18_f468b33164fe02e7fa601be000d216a2'><input  type=\"radio\" name=\"input_radio_18\" data-name=\"input_radio_18\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Unsure \/ Discuss with Therapist\"  id='input_radio_18_f468b33164fe02e7fa601be000d216a2' aria-label='Unsure \/ Discuss with Therapist' aria-invalid='false' aria-required=false> <span>Unsure \/ Discuss with Therapist<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Best Way to Confirm Appointments\">Best Way to Confirm Appointments<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_19_c6860c19610e96efab5b927f0ae1b67a'><input  type=\"radio\" name=\"input_radio_19\" data-name=\"input_radio_19\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Phone Call\"  id='input_radio_19_c6860c19610e96efab5b927f0ae1b67a' aria-label='Phone Call' aria-invalid='false' aria-required=false> <span>Phone Call<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_19_74086537f73d6cc28dd9644dabf12e52'><input  type=\"radio\" name=\"input_radio_19\" data-name=\"input_radio_19\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Text Message\"  id='input_radio_19_74086537f73d6cc28dd9644dabf12e52' aria-label='Text Message' aria-invalid='false' aria-required=false> <span>Text Message<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_19_2cc80fea0040debed2e52f8ebd0ac89d'><input  type=\"radio\" name=\"input_radio_19\" data-name=\"input_radio_19\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Email\"  id='input_radio_19_2cc80fea0040debed2e52f8ebd0ac89d' aria-label='Email' aria-invalid='false' aria-required=false> <span>Email<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_19_edc66d565d9cd7e9ccb799f62d758a0e'><input  type=\"radio\" name=\"input_radio_19\" data-name=\"input_radio_19\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Patient Portal\"  id='input_radio_19_edc66d565d9cd7e9ccb799f62d758a0e' aria-label='Patient Portal' aria-invalid='false' aria-required=false> <span>Patient Portal<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_22\" ><p><strong>Scheduling Notes<\/strong><\/p>\n<p>Please include any information that may affect scheduling (work schedule, childcare needs, rotating shifts, travel, etc.):<\/p><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Schedule Now\">Schedule Now<\/button><\/div><\/fieldset><\/form><div id='fluentform_4_errors' class='ff-errors-in-stack ff_form_instance_4_1 ff-form-loading_errors ff_form_instance_4_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_4_1 = {\"id\":\"4\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_4_1\",\"form_id_selector\":\"fluentform_4\",\"rules\":{\"names[first_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[last_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"datetime\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address_1[address_line_1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address_1[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address_1[city]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address_1[state]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address_1[zip]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address_1[country]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"phone\":{\"required\":{\"value\":false,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"global\":true,\"message\":\"Phone number is not valid\",\"global_message\":\"Phone number is not valid\"}},\"email\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global_message\":\"This field must contain a valid email\",\"global\":true}},\"checkbox\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"phone_1\":{\"required\":{\"value\":false,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"global\":true,\"message\":\"Phone number is not valid\",\"global_message\":\"Phone number is not valid\"}},\"input_text_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"numeric_field\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"numeric_field_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"input_text_5\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"datetime_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_6\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"numeric_field_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"numeric_field_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"input_text_7\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_8\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_9\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_2\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_4\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_7\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_8\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_9\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_10\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_11\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"datetime_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_12\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_13\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_14\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"datetime_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_15\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_16\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_5\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_6\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_7\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_8\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_17\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_9\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_10\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_18\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_19\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description_5\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_11\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_20\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_12\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_21\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_13\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_22\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_14\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_23\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_15\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_16\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_24\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_10\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_11\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"gdpr-agreement_12\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"signature\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"datetime_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"signature_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"datetime_5\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"signature_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"datetime_6\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_17\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"repeater_container[0]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"repeater_container[1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_18\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_19\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}}},\"debounce_time\":300,\"conditionals\":{\"input_text_9\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_1\",\"value\":\"Other\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_11\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_2\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"datetime_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_2\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_12\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_2\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"description_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_3\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_13\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_4\",\"value\":\"Other\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_17\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_8\",\"value\":\"Yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_18\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_10\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_21\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_12\",\"value\":\"Other\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_22\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_13\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_23\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_14\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"input_text_24\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_16\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]}}};\n                            <\/script>\n            \n\t\t<\/div>\n\t\t[\/vc_column][vc_column width=&#8221;1\/6&#8243;][\/vc_column][\/vc_row][\/vc_section]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_section][vc_row][vc_column width=&#8221;1\/6&#8243;][\/vc_column][vc_column width=&#8221;2\/3&#8243;][\/vc_column][vc_column width=&#8221;1\/6&#8243;][\/vc_column][\/vc_row][\/vc_section]<\/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-334","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/pages\/334","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/comments?post=334"}],"version-history":[{"count":2,"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/pages\/334\/revisions"}],"predecessor-version":[{"id":336,"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/pages\/334\/revisions\/336"}],"wp:attachment":[{"href":"https:\/\/demolinks2.com\/empower-mental-health\/wp-json\/wp\/v2\/media?parent=334"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}