{"id":936,"date":"2022-04-25T03:15:50","date_gmt":"2022-04-25T03:15:50","guid":{"rendered":"https:\/\/anewlifeinchristministriesandresources.com\/?page_id=936"},"modified":"2026-08-18T11:04:30","modified_gmt":"2026-08-18T11:04:30","slug":"referral-screening-form","status":"publish","type":"page","link":"https:\/\/anewlifeinchristministriesandresources.com\/ht\/referral-screening-form","title":{"rendered":"Referral Screening Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"936\" class=\"elementor elementor-936\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1171a7b elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"1171a7b\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-cefadbb\" data-id=\"cefadbb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-80c4821 elementor-widget elementor-widget-html\" data-id=\"80c4821\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!--\r\n================================================================================\r\nREFERRAL SCREENING FORM  -  \/referral-screening-form\/\r\nElementor HTML Widget  -  Build v1.0  -  August 17, 2026\r\n\r\nWHAT THIS FILE IS\r\nThis does NOT rebuild the form. Rebuilding 87 Elementor fields by hand would be\r\nslow and risky. Instead this file provides:\r\n\r\n   1. A crisis notice and intro block to place ABOVE the existing form\r\n   2. A complete CSS restyle that targets Elementor's own form classes and\r\n      brings the form into the site color scheme\r\n   3. A closing block to place BELOW the form\r\n\r\nINSTALL\r\n   1. Edit \/referral-screening-form\/ in Elementor\r\n   2. Add an HTML widget ABOVE the existing Form widget\r\n   3. Paste this entire file into it\r\n   4. Leave the Form widget exactly as it is - the CSS restyles it in place\r\n   5. Purge GoDaddy cache and Elementor CSS cache\r\n\r\n*** THREE ISSUES TO RESOLVE - SEE THE NOTES AT THE END OF THIS FILE ***\r\n   A. Crisis fields with no crisis pathway\r\n   B. Protected health information sent by email\r\n   C. This page must NOT be redirected to \/get-help\/\r\n================================================================================\r\n-->\r\n\r\n<div class=\"anl-form-page\">\r\n\r\n<style>\r\n\/* ============================================================\r\n   Scoped restyle. .anl-form-page wraps this block; the form\r\n   selectors reach the Elementor Form widget that follows it\r\n   on the same page.\r\n   ============================================================ *\/\r\n\r\n.anl-form-page *, .anl-form-page *::before, .anl-form-page *::after { box-sizing: border-box !important; }\r\n\r\n.anl-form-page {\r\n  font-family: -apple-system, BlinkMacSystemFont, \"Segoe UI\", Roboto, \"Helvetica Neue\", Arial, sans-serif !important;\r\n  font-size: 17px !important; line-height: 1.65 !important; color: #14201B !important;\r\n  -webkit-text-size-adjust: 100% !important;\r\n  padding-left: env(safe-area-inset-left, 0px) !important;\r\n  padding-right: env(safe-area-inset-right, 0px) !important;\r\n}\r\n.anl-form-page p { margin: 0 0 16px 0 !important; max-width: 70ch !important; }\r\n.anl-form-page h1, .anl-form-page h2, .anl-form-page h3 {\r\n  font-family: inherit !important; color: #14201B !important; margin: 0 0 14px 0 !important;\r\n  line-height: 1.24 !important; letter-spacing: -0.015em !important;\r\n}\r\n.anl-form-page h1 { font-size: clamp(27px, 5.6vw, 40px) !important; font-weight: 800 !important; }\r\n.anl-form-page h2 { font-size: clamp(21px, 4vw, 28px) !important; font-weight: 750 !important; }\r\n.anl-form-page ul { list-style: none !important; margin: 0 !important; padding: 0 !important; }\r\n.anl-form-page a { color: #0B5D3B !important; text-decoration: underline !important; }\r\n.anl-form-page a:hover { color: #0F7A38 !important; }\r\n\r\n.anl-fwrap { max-width: 960px !important; margin: 0 auto !important; padding: 0 18px !important; }\r\n\r\n\/* ---------- Crisis notice ---------- *\/\r\n.anl-alert {\r\n  background: #B91C1C !important; color: #FFFFFF !important;\r\n  border-radius: 10px !important; padding: 22px 24px !important; margin-bottom: 26px !important;\r\n}\r\n.anl-alert h2 { color: #FFFFFF !important; font-size: 21px !important; margin-bottom: 10px !important; }\r\n.anl-alert p { color: #FFFFFF !important; margin-bottom: 10px !important; }\r\n.anl-alert p:last-child { margin-bottom: 0 !important; }\r\n.anl-alert strong { color: #FFFFFF !important; }\r\n.anl-alert a { color: #FFFFFF !important; text-decoration: underline !important; font-weight: 700 !important; }\r\n.anl-alert a:hover { color: #FFE4E4 !important; }\r\n\r\n\/* ---------- Header ---------- *\/\r\n.anl-fhero {\r\n  background: #0B5D3B !important; color: #FFFFFF !important;\r\n  border-radius: 10px !important; padding: 30px 26px !important; margin-bottom: 26px !important;\r\n}\r\n.anl-fhero h1, .anl-fhero p, .anl-fhero strong { color: #FFFFFF !important; }\r\n.anl-fhero p { color: #E8F2EC !important; }\r\n.anl-eyebrow {\r\n  display: inline-block !important; background: rgba(255,255,255,.14) !important; color: #FFFFFF !important;\r\n  font-size: 13px !important; font-weight: 700 !important; letter-spacing: .09em !important;\r\n  text-transform: uppercase !important; padding: 7px 13px !important;\r\n  border-radius: 4px !important; margin-bottom: 14px !important;\r\n}\r\n\r\n.anl-panel {\r\n  background: #F4F6F5 !important; border: 1px solid #D8E2DC !important;\r\n  border-left: 5px solid #0F7A38 !important; border-radius: 8px !important;\r\n  padding: 22px 24px !important; margin-bottom: 26px !important;\r\n}\r\n.anl-panel h2 { font-size: 20px !important; margin-bottom: 12px !important; }\r\n.anl-panel p:last-child, .anl-panel ul:last-child { margin-bottom: 0 !important; }\r\n.anl-panel li { position: relative !important; padding-left: 30px !important; margin-bottom: 11px !important; }\r\n.anl-panel li::before {\r\n  content: \"\\2713\" !important; position: absolute !important; left: 0 !important; top: 0 !important;\r\n  color: #0F7A38 !important; font-weight: 800 !important; font-size: 18px !important;\r\n}\r\n\r\n\/* ============================================================\r\n   ELEMENTOR FORM RESTYLE\r\n   Targets Elementor's generated classes. High specificity so it\r\n   beats both Elementor defaults and OceanWP.\r\n   ============================================================ *\/\r\n\r\n.elementor-widget-form .elementor-form {\r\n  background: #FFFFFF !important;\r\n  border: 1px solid #D8E2DC !important;\r\n  border-radius: 12px !important;\r\n  padding: 26px 22px !important;\r\n}\r\n\r\n\/* field group spacing *\/\r\n.elementor-widget-form .elementor-form .elementor-field-group {\r\n  margin-bottom: 20px !important;\r\n  padding-right: 0 !important;\r\n}\r\n\r\n\/* labels *\/\r\n.elementor-widget-form .elementor-form .elementor-field-group > label,\r\n.elementor-widget-form .elementor-form .elementor-field-label {\r\n  display: block !important;\r\n  font-family: -apple-system, BlinkMacSystemFont, \"Segoe UI\", Roboto, Arial, sans-serif !important;\r\n  font-size: 16px !important;\r\n  font-weight: 700 !important;\r\n  color: #14201B !important;\r\n  margin-bottom: 7px !important;\r\n  line-height: 1.4 !important;\r\n  cursor: pointer !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-mark-required .elementor-field-label:after {\r\n  content: \" *\" !important; color: #B91C1C !important; font-weight: 800 !important;\r\n}\r\n\r\n\/* text inputs, selects, textareas\r\n   17px is deliberate - anything under 16px makes iOS Safari zoom on focus *\/\r\n.elementor-widget-form .elementor-form input[type=\"text\"],\r\n.elementor-widget-form .elementor-form input[type=\"email\"],\r\n.elementor-widget-form .elementor-form input[type=\"tel\"],\r\n.elementor-widget-form .elementor-form input[type=\"url\"],\r\n.elementor-widget-form .elementor-form input[type=\"number\"],\r\n.elementor-widget-form .elementor-form input[type=\"date\"],\r\n.elementor-widget-form .elementor-form select,\r\n.elementor-widget-form .elementor-form textarea {\r\n  width: 100% !important;\r\n  min-height: 52px !important;\r\n  padding: 13px 15px !important;\r\n  font-family: inherit !important;\r\n  font-size: 17px !important;\r\n  line-height: 1.45 !important;\r\n  color: #14201B !important;\r\n  background-color: #FFFFFF !important;\r\n  border: 1.5px solid #C6D6CE !important;\r\n  border-radius: 7px !important;\r\n  box-shadow: none !important;\r\n  -webkit-appearance: none !important;\r\n  appearance: none !important;\r\n  transition: none !important;\r\n}\r\n.elementor-widget-form .elementor-form textarea { min-height: 120px !important; padding-top: 13px !important; }\r\n\r\n.elementor-widget-form .elementor-form select {\r\n  background-image: url(\"data:image\/svg+xml;charset=UTF-8,%3Csvg xmlns='http:\/\/www.w3.org\/2000\/svg' viewBox='0 0 24 24' fill='none' stroke='%230B5D3B' stroke-width='2.5'%3E%3Cpath d='M6 9l6 6 6-6'\/%3E%3C\/svg%3E\") !important;\r\n  background-repeat: no-repeat !important;\r\n  background-position: right 14px center !important;\r\n  background-size: 20px !important;\r\n  padding-right: 44px !important;\r\n}\r\n\r\n.elementor-widget-form .elementor-form input:focus,\r\n.elementor-widget-form .elementor-form select:focus,\r\n.elementor-widget-form .elementor-form textarea:focus {\r\n  border-color: #0F7A38 !important;\r\n  outline: 3px solid rgba(15,122,56,.25) !important;\r\n  outline-offset: 0 !important;\r\n}\r\n.elementor-widget-form .elementor-form input::placeholder,\r\n.elementor-widget-form .elementor-form textarea::placeholder {\r\n  color: #7C8B84 !important; opacity: 1 !important;\r\n}\r\n\r\n\/* checkboxes and radios - large enough to hit reliably *\/\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup {\r\n  display: block !important;\r\n  background: #F4F6F5 !important;\r\n  border: 1px solid #D8E2DC !important;\r\n  border-radius: 8px !important;\r\n  padding: 8px 14px !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup .elementor-field-option {\r\n  display: flex !important;\r\n  align-items: flex-start !important;\r\n  gap: 11px !important;\r\n  padding: 11px 0 !important;\r\n  border-bottom: 1px solid #E4EBE7 !important;\r\n  min-height: 48px !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup .elementor-field-option:last-child {\r\n  border-bottom: 0 !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup input[type=\"checkbox\"],\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup input[type=\"radio\"] {\r\n  width: 24px !important; height: 24px !important;\r\n  min-width: 24px !important; margin: 1px 0 0 0 !important;\r\n  accent-color: #0F7A38 !important; cursor: pointer !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup label {\r\n  font-size: 16.5px !important; font-weight: 500 !important;\r\n  color: #14201B !important; margin: 0 !important;\r\n  line-height: 1.45 !important; cursor: pointer !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-field-subgroup.elementor-subgroup-inline {\r\n  display: flex !important; flex-wrap: wrap !important; gap: 0 22px !important;\r\n}\r\n\r\n\/* submit button - white on #0F7A38 measures 5.44:1, passes WCAG AA *\/\r\n.elementor-widget-form .elementor-form .elementor-field-type-submit { margin-top: 8px !important; }\r\n.elementor-widget-form .elementor-form button[type=\"submit\"],\r\n.elementor-widget-form .elementor-form .elementor-button {\r\n  width: 100% !important;\r\n  min-height: 56px !important;\r\n  padding: 16px 30px !important;\r\n  font-family: inherit !important;\r\n  font-size: 18px !important;\r\n  font-weight: 700 !important;\r\n  color: #FFFFFF !important;\r\n  -webkit-text-fill-color: #FFFFFF !important;\r\n  background-color: #0F7A38 !important;\r\n  border: 0 !important;\r\n  border-radius: 7px !important;\r\n  box-shadow: none !important;\r\n  cursor: pointer !important;\r\n  transition: none !important;\r\n}\r\n.elementor-widget-form .elementor-form button[type=\"submit\"]:hover,\r\n.elementor-widget-form .elementor-form .elementor-button:hover,\r\n.elementor-widget-form .elementor-form button[type=\"submit\"]:focus,\r\n.elementor-widget-form .elementor-form .elementor-button:focus {\r\n  background-color: #0B5D3B !important;\r\n  color: #FFFFFF !important;\r\n  -webkit-text-fill-color: #FFFFFF !important;\r\n}\r\n.elementor-widget-form .elementor-form button[type=\"submit\"]:focus-visible {\r\n  outline: 3px solid #FACC15 !important; outline-offset: 3px !important;\r\n}\r\n@media (min-width: 700px) {\r\n  .elementor-widget-form .elementor-form button[type=\"submit\"],\r\n  .elementor-widget-form .elementor-form .elementor-button { width: auto !important; min-width: 280px !important; }\r\n}\r\n\r\n\/* messages *\/\r\n.elementor-widget-form .elementor-message {\r\n  font-size: 16.5px !important; padding: 14px 16px !important;\r\n  border-radius: 7px !important; margin-top: 14px !important;\r\n}\r\n.elementor-widget-form .elementor-message.elementor-message-success {\r\n  background: #ECFDF3 !important; color: #0B5D3B !important; border: 1px solid #A7E3BF !important;\r\n}\r\n.elementor-widget-form .elementor-message.elementor-message-danger {\r\n  background: #FEF2F2 !important; color: #991B1B !important; border: 1px solid #FCA5A5 !important;\r\n}\r\n.elementor-widget-form .elementor-form .elementor-field-group.elementor-error input,\r\n.elementor-widget-form .elementor-form .elementor-field-group.elementor-error select,\r\n.elementor-widget-form .elementor-form .elementor-field-group.elementor-error textarea {\r\n  border-color: #B91C1C !important;\r\n}\r\n\r\n\/* single column on mobile, always *\/\r\n@media (max-width: 767px) {\r\n  .elementor-widget-form .elementor-form .elementor-field-group {\r\n    width: 100% !important; flex-basis: 100% !important; max-width: 100% !important;\r\n  }\r\n  .elementor-widget-form .elementor-form { padding: 20px 16px !important; }\r\n}\r\n\r\n@media (prefers-reduced-motion: reduce) {\r\n  .anl-form-page *, .elementor-widget-form * { transition-duration: .01ms !important; animation-duration: .01ms !important; }\r\n}\r\n@media print {\r\n  .anl-alert { border: 3px solid #000 !important; background: #FFF !important; }\r\n  .anl-alert h2, .anl-alert p, .anl-alert strong, .anl-alert a { color: #000 !important; }\r\n  .anl-fhero { background: #FFF !important; }\r\n  .anl-fhero h1, .anl-fhero p { color: #000 !important; }\r\n}\r\n\r\n\r\n\r\n\r\n\/* ============================================================\r\n   TYPOGRAPHY LAYER \u2014 LAST BLOCK IN THIS STYLESHEET.\r\n\r\n   Sets ONLY four things, at a specificity high enough to beat OceanWP's\r\n   ID-based selectors (#main p is (1,0,1) and outranks any class rule\r\n   regardless of !important):\r\n\r\n       font-weight   \u2014 nothing declared it before, so body copy inherited\r\n                       OceanWP's weight and rendered bold everywhere\r\n       margin-bottom \u2014 the paragraph spacing that was collapsing\r\n       line-height\r\n       max-width     \u2014 one measure shared by headings and body copy\r\n\r\n   IT DOES NOT SET COLOR on body copy. An earlier version did, and it flattened\r\n   every deliberate colour in the design \u2014 muted card text, notes, captions,\r\n   the reverse-out text on the dark panels. Colour is left to the base rules.\r\n   The only colour declarations here are the reverse-out panels, because those\r\n   are the ones OceanWP link and text colours actually break.\r\n   ============================================================ *\/\r\n\r\n\/* --- WEIGHT --- *\/\r\nhtml body .anl-form-page.anl-form-page p, html body .anl-form-page.anl-form-page li,\r\nhtml body .anl-form-page.anl-form-page td, html body .anl-form-page.anl-form-page address,\r\n#main .anl-form-page.anl-form-page p, #main .anl-form-page.anl-form-page li,\r\n#content .anl-form-page.anl-form-page p, #content .anl-form-page.anl-form-page li,\r\n#content-wrap .anl-form-page.anl-form-page p, #content-wrap .anl-form-page.anl-form-page li,\r\n#primary .anl-form-page.anl-form-page p, #primary .anl-form-page.anl-form-page li,\r\n.elementor-widget-container .anl-form-page.anl-form-page p,\r\n.elementor-widget-container .anl-form-page.anl-form-page li{font-weight:400 !important;}\r\n\r\nhtml body .anl-form-page.anl-form-page strong, html body .anl-form-page.anl-form-page b, html body .anl-form-page.anl-form-page th,\r\n#main .anl-form-page.anl-form-page strong, #content-wrap .anl-form-page.anl-form-page strong,\r\n.elementor-widget-container .anl-form-page.anl-form-page strong{font-weight:700 !important;}\r\n\r\nhtml body .anl-form-page.anl-form-page h1, #main .anl-form-page.anl-form-page h1,\r\n.elementor-widget-container .anl-form-page.anl-form-page h1{font-weight:800 !important;}\r\nhtml body .anl-form-page.anl-form-page h2, html body .anl-form-page.anl-form-page h3,\r\n#main .anl-form-page.anl-form-page h2, #main .anl-form-page.anl-form-page h3,\r\n#content-wrap .anl-form-page.anl-form-page h2, #content-wrap .anl-form-page.anl-form-page h3,\r\n.elementor-widget-container .anl-form-page.anl-form-page h2,\r\n.elementor-widget-container .anl-form-page.anl-form-page h3{font-weight:700 !important;}\r\n\r\n\/* --- SPACING. This is the fix for paragraphs sitting squeezed together. --- *\/\r\nhtml body .anl-form-page.anl-form-page .anl-sec p, html body .anl-form-page.anl-form-page .anl-hero p,\r\n#main .anl-form-page.anl-form-page .anl-sec p, #content .anl-form-page.anl-form-page .anl-sec p,\r\n#content-wrap .anl-form-page.anl-form-page .anl-sec p, #primary .anl-form-page.anl-form-page .anl-sec p,\r\n.elementor-widget-container .anl-form-page.anl-form-page .anl-sec p{\r\n  margin:0 0 22px 0 !important;line-height:1.75 !important;}\r\n\r\nhtml body .anl-form-page.anl-form-page .anl-sec h2,\r\n#main .anl-form-page.anl-form-page .anl-sec h2,\r\n.elementor-widget-container .anl-form-page.anl-form-page .anl-sec h2{margin:0 0 20px 0 !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-sec h3,\r\n#main .anl-form-page.anl-form-page .anl-sec h3{margin:32px 0 12px 0 !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-sec h3:first-child{margin-top:0 !important;}\r\n\r\nhtml body .anl-form-page.anl-form-page .anl-check li,\r\n#main .anl-form-page.anl-form-page .anl-check li{margin:0 0 15px 0 !important;line-height:1.7 !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-steps li,\r\n#main .anl-form-page.anl-form-page .anl-steps li{margin:0 0 26px 0 !important;line-height:1.7 !important;}\r\n\r\nhtml body .anl-form-page.anl-form-page .anl-sec,\r\n#main .anl-form-page.anl-form-page .anl-sec{padding:54px 0 !important;}\r\n@media (min-width:900px){\r\nhtml body .anl-form-page.anl-form-page .anl-sec, #main .anl-form-page.anl-form-page .anl-sec{padding:68px 0 !important;}}\r\n\r\n\/* --- MEASURE. Headings and body copy share one right edge. --- *\/\r\nhtml body .anl-form-page.anl-form-page .anl-sec .anl-wrap > h2,\r\nhtml body .anl-form-page.anl-form-page .anl-sec .anl-wrap > h3,\r\nhtml body .anl-form-page.anl-form-page .anl-sec .anl-wrap > p,\r\nhtml body .anl-form-page.anl-form-page .anl-sec .anl-wrap > ul,\r\nhtml body .anl-form-page.anl-form-page .anl-sec .anl-wrap > ol,\r\n#main .anl-form-page.anl-form-page .anl-sec .anl-wrap > p,\r\n#content-wrap .anl-form-page.anl-form-page .anl-sec .anl-wrap > p,\r\n.elementor-widget-container .anl-form-page.anl-form-page .anl-sec .anl-wrap > h2,\r\n.elementor-widget-container .anl-form-page.anl-form-page .anl-sec .anl-wrap > p{\r\n  max-width:720px !important;margin-left:0 !important;margin-right:0 !important;}\r\n\r\n\/* Full-width components keep the container. *\/\r\nhtml body .anl-form-page.anl-form-page .anl-cards, html body .anl-form-page.anl-form-page .anl-next,\r\nhtml body .anl-form-page.anl-form-page .anl-tablewrap, html body .anl-form-page.anl-form-page .anl-split,\r\nhtml body .anl-form-page.anl-form-page .anl-loc, html body .anl-form-page.anl-form-page .anl-callout,\r\nhtml body .anl-form-page.anl-form-page .anl-calls, html body .anl-form-page.anl-form-page .anl-jump,\r\nhtml body .anl-form-page.anl-form-page .anl-btns, html body .anl-form-page.anl-form-page .anl-map,\r\nhtml body .anl-form-page.anl-form-page .anl-figure,\r\nhtml body .anl-form-page.anl-form-page .anl-card p, html body .anl-form-page.anl-form-page .anl-loc p,\r\nhtml body .anl-form-page.anl-form-page .anl-loc address, html body .anl-form-page.anl-form-page .anl-callout p,\r\nhtml body .anl-form-page.anl-form-page .anl-calls p, html body .anl-form-page.anl-form-page .anl-areas p,\r\nhtml body .anl-form-page.anl-form-page .anl-next-card span{max-width:none !important;}\r\n\r\nhtml body .anl-form-page.anl-form-page .anl-crisis p{max-width:1044px !important;margin:0 auto !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-announce p{max-width:none !important;width:100% !important;margin:0 !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-card p, html body .anl-form-page.anl-form-page .anl-next-card span{margin:0 !important;line-height:1.65 !important;}\r\n\r\n\/* Elementor pads its widget container; the page's own wrapper should control this. *\/\r\n.elementor-widget-container > .anl-form-page{padding-left:0 !important;padding-right:0 !important;}\r\n\r\n\/* --- REVERSE-OUT PANELS. The only colour set here, because OceanWP text and\r\n       link colours do break these. --- *\/\r\nhtml body .anl-form-page.anl-form-page .anl-hero h1, html body .anl-form-page.anl-form-page .anl-hero strong{color:#FFFFFF !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-hero p{color:#E8F2EC !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-loc p, html body .anl-form-page.anl-form-page .anl-loc h2,\r\nhtml body .anl-form-page.anl-form-page .anl-loc h3, html body .anl-form-page.anl-form-page .anl-loc address,\r\nhtml body .anl-form-page.anl-form-page .anl-loc strong{color:#FFFFFF !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-loc a{color:#FFFFFF !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-crisis p, html body .anl-form-page.anl-form-page .anl-crisis strong{color:#FFFFFF !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-crisis a{color:#FFFFFF !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-announce p, html body .anl-form-page.anl-form-page .anl-announce strong{color:#14201B !important;}\r\nhtml body .anl-form-page.anl-form-page .anl-flag{color:#14201B !important;-webkit-text-fill-color:#14201B !important;}\r\n\r\n<\/style>\r\n\r\n\r\n<div class=\"anl-fwrap\">\r\n\r\n  <!-- ========== CRISIS NOTICE \u2014 must stay above the form ========== -->\r\n  <div class=\"anl-alert\" role=\"alert\">\r\n    <h2>If this is an emergency, do not use this form<\/h2>\r\n    <p>This form is checked during office hours only. It is <strong>not<\/strong> monitored around the clock, and submitting it does not alert anyone immediately.<\/p>\r\n    <p><strong>If the person you are referring is in danger right now:<\/strong><\/p>\r\n    <p>\r\n      Call <a href=\"tel:911\">911<\/a> for immediate danger &nbsp;&middot;&nbsp;\r\n      Call or text <a href=\"tel:988\">988<\/a> for the Suicide &amp; Crisis Lifeline, 24 hours &nbsp;&middot;&nbsp;\r\n      Call <a href=\"tel:211\">211<\/a> for 24-hour crisis counselling in English, Spanish, and Creole &nbsp;&middot;&nbsp;\r\n      Call the Florida Abuse Hotline at <a href=\"tel:18009622873\">1-800-962-2873<\/a> to report abuse or neglect\r\n    <\/p>\r\n  <\/div>\r\n\r\n\r\n  <!-- ========== HEADER ========== -->\r\n  <div class=\"anl-fhero\">\r\n    <span class=\"anl-eyebrow\">For referring professionals<\/span>\r\n    <h1>Referral Screening Form<\/h1>\r\n    <p>Use this form to refer a client to A New Life in Christ Ministries and Resources for outpatient services, individual and family counselling, substance abuse support, the SEED after-school program, or PSR for adults.<\/p>\r\n    <p><strong>This form is for schools, agencies, clinicians, and caseworkers.<\/strong> If you are a family looking for help for yourself, please <a href=\"https:\/\/anewlifeinchristministriesandresources.com\/get-help\/\">request an appointment here<\/a> instead, or call (786) 396-3144.<\/p>\r\n  <\/div>\r\n\r\n\r\n  <!-- ========== BEFORE YOU START ========== -->\r\n  <div class=\"anl-panel\">\r\n    <h2>Before you start<\/h2>\r\n    <ul>\r\n      <li><strong>This form is long.<\/strong> It collects clinical and demographic detail, so allow about 15 minutes and gather what you need first.<\/li>\r\n      <li><strong>It does not save partway through.<\/strong> Finish in one sitting.<\/li>\r\n      <li><strong>Have ready:<\/strong> client name and address, date of birth, guardian and emergency contact details, insurance or Medicaid number, primary care physician details, school and grade, and the presenting concerns.<\/li>\r\n      <li><strong>Only share what you are authorised to share.<\/strong> Make sure you have the consent or release you need before submitting clinical information about a client.<\/li>\r\n      <li><strong>Questions?<\/strong> Call <a href=\"tel:+17863963144\">(786) 396-3144<\/a> before submitting if you are unsure whether this is the right referral route.<\/li>\r\n    <\/ul>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n<!-- The existing Elementor Form widget follows below this widget.\r\n     Do not move it. The CSS above restyles it in place. -->\r\n\r\n<\/div><!-- \/.anl-form-page -->\r\n\r\n\r\n<!--\r\n================================================================================\r\nTHREE ISSUES TO RESOLVE  -  RAISED 2026-08-17\r\n================================================================================\r\n\r\nA. CRISIS FIELDS WITH NO CRISIS PATHWAY  ***HIGHEST PRIORITY***\r\n\r\n   The form contains checkboxes for Suicidal Ideation, Homicidal Ideation,\r\n   Sexual Abuse Victim, Danger to Self or Others, and Baker Act \/ Marchman Act\r\n   history.\r\n\r\n   A school counsellor can tick \"Suicidal Ideation\" and submit a web form that\r\n   nobody reads until Monday.\r\n\r\n   The crisis notice added above is a first step, not a solution. What is also\r\n   needed:\r\n     - A defined internal process for what happens when one of those boxes is\r\n       ticked, and who is responsible for seeing it\r\n     - An automated alert - email plus SMS - to a named person when those\r\n       fields are checked, not just a normal submission notice\r\n     - A stated response time on the page, e.g. \"we respond within one business\r\n       day\", so the referrer knows what to expect\r\n   This is an operational question for Pastor Hall, not a design question.\r\n\r\n\r\nB. PROTECTED HEALTH INFORMATION SENT BY EMAIL  ***URGENT***\r\n\r\n   This form collects: mental health symptoms, suicidal and homicidal ideation,\r\n   substance abuse history, sexual abuse history, psychiatric diagnoses,\r\n   Medicaid and insurance ID numbers, and physician details. That is protected\r\n   health information.\r\n\r\n   Elementor Forms by default emails submissions in plain text AND stores them\r\n   in the WordPress database. Neither is appropriate for this data.\r\n\r\n   Confirm with the organization's counsel or compliance advisor:\r\n     - Is A New Life a HIPAA covered entity or a business associate of one?\r\n     - If yes, plain email delivery is very likely non-compliant\r\n     - Even if not HIPAA-covered, emailing unencrypted suicidal-ideation data\r\n       about a named minor is a serious risk regardless of the law\r\n\r\n   Options to raise:\r\n     - Disable database storage of entries in the Elementor form settings\r\n     - Send a notification containing NO client data - just \"a referral was\r\n       submitted, log in to view\"\r\n     - Move clinical intake to a HIPAA-capable platform such as Jotform HIPAA,\r\n       Formstack, or a behavioral health EHR, and keep only a short contact\r\n       form on the website\r\n   Recommendation: do not publish the restyled page until this is answered.\r\n\r\n\r\nC. DO NOT REDIRECT THIS PAGE TO \/get-help\/  ***CORRECTION***\r\n\r\n   The build README lists:  301  \/referral-screening-form -> \/get-help\/\r\n   That instruction is WRONG and must be removed.\r\n\r\n   These are different pages for different people:\r\n     \/referral-screening-form  = clinical referral, completed by professionals\r\n     \/get-help\/                = simple family intake, 8 fields, self-referral\r\n     \/school-resource-referral-form\/ = check whether this duplicates the above\r\n\r\n   Redirecting the clinical form to a family intake page would break the\r\n   referral pipeline from schools and agencies, which is one of the\r\n   organization's strongest assets.\r\n\r\n   Also check whether \/school-resource-referral-form\/ and this page overlap.\r\n   If they do, consolidate deliberately rather than leaving two similar forms.\r\n\r\n\r\nALSO WORTH FIXING WHILE YOU ARE IN THERE\r\n   - Typo: \"Legal Guardian Ralationship\"  ->  \"Relationship\"\r\n   - Typo: \"Sucidial Ideation\"            ->  \"Suicidal Ideation\"\r\n   - Consider Elementor's multi-step feature to break 87 fields into 5 steps.\r\n     A single 87-field page is a very high abandonment risk, even for\r\n     professional users.\r\n================================================================================\r\n-->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ec08704 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"ec08704\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ee1fd94\" data-id=\"ee1fd94\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e7485ef elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"e7485ef\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Referral\/Screening Form\" aria-label=\"Referral\/Screening Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"936\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"e7485ef\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Referral Screening Form - A New Life in Christ Ministries and Resources Inc\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"936\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8a6a3c4 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8a6a3c4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOutpatient Programs\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Individual\/Family Counseling\" id=\"form-field-field_8a6a3c4-0\" name=\"form_fields[field_8a6a3c4][]\"> <label for=\"form-field-field_8a6a3c4-0\">Individual\/Family Counseling<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Substance Abuse\" id=\"form-field-field_8a6a3c4-1\" name=\"form_fields[field_8a6a3c4][]\"> <label for=\"form-field-field_8a6a3c4-1\">Substance Abuse<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"SEED (After School Program)\" id=\"form-field-field_8a6a3c4-2\" name=\"form_fields[field_8a6a3c4][]\"> <label for=\"form-field-field_8a6a3c4-2\">SEED (After School Program)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"PSR Adults\" id=\"form-field-field_8a6a3c4-3\" name=\"form_fields[field_8a6a3c4][]\"> <label for=\"form-field-field_8a6a3c4-3\">PSR Adults<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-30 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClient First Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d7a5440 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d7a5440\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClient Middle Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d7a5440]\" id=\"form-field-field_d7a5440\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4d3513e elementor-col-30 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4d3513e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClient Last Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4d3513e]\" id=\"form-field-field_4d3513e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c7c6d3c elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c7c6d3c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c7c6d3c]\" id=\"form-field-field_c7c6d3c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Address\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_af47cbe elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_af47cbe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_af47cbe]\" id=\"form-field-field_af47cbe\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1e5f62d elementor-col-25 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1e5f62d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1e5f62d]\" id=\"form-field-field_1e5f62d\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"AL\tAlabama\">AL\tAlabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AK\tAlaska\">AK\tAlaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\tArizona\">AZ\tArizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\tArkansas\">AR\tArkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\tCalifornia\">CA\tCalifornia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\tColorado\">CO\tColorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CT\tConnecticut\">CT\tConnecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\tDelaware\">DE\tDelaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DC\tDistrict Of Columbia\">DC\tDistrict Of Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FL\tFlorida\">FL\tFlorida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\tGeorgia\">GA\tGeorgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HI\tHawaii\">HI\tHawaii<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\tIdaho\">ID\tIdaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\tIllinois\">IL\tIllinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\tIndiana\">IN\tIndiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IA\tIowa\">IA\tIowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KS\tKansas\">KS\tKansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KY\tKentucky\">KY\tKentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\tLouisiana\">LA\tLouisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\tMaine\">ME\tMaine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\tMaryland\">MD\tMaryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\tMassachusetts\">MA\tMassachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MI\tMichigan\">MI\tMichigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\tMinnesota\">MN\tMinnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MS\tMississippi\">MS\tMississippi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MO\tMissouri\">MO\tMissouri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\tMontana\">MT\tMontana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\tNebraska\">NE\tNebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NV\tNevada\">NV\tNevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NH\tNew Hampshire\">NH\tNew Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NJ\tNew Jersey\">NJ\tNew Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NM\tNew Mexico\">NM\tNew Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NY\tNew York\">NY\tNew York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NC\tNorth Carolina\">NC\tNorth Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ND\tNorth Dakota\">ND\tNorth Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OH\tOhio\">OH\tOhio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OK\tOklahoma\">OK\tOklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OR\tOregon\">OR\tOregon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\tPennsylvania\">PA\tPennsylvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RI\tRhode Island\">RI\tRhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\tSouth Carolina\">SC\tSouth Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\tSouth Dakota\">SD\tSouth Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\tTennessee\">TN\tTennessee<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TX\tTexas\">TX\tTexas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UT\tUtah\">UT\tUtah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VT\tVermont\">VT\tVermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\tVirginia\">VA\tVirginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WA\tWashington\">WA\tWashington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WV\tWest Virginia\">WV\tWest Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WI\tWisconsin\">WI\tWisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WY\tWyoming\">WY\tWyoming<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AS   American Samoa\">AS   American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GU  Guam\">GU  Guam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MP  Northern Mariana Islands\">MP  Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PR   Puerto Rico\">PR   Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VI    US Virgin Islands\">VI    US Virgin Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DC   Washington, DC\">DC   Washington, DC<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_777ca40 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_777ca40\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZip Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_777ca40]\" id=\"form-field-field_777ca40\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Zip Code\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_6c97db9 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6c97db9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_6c97db9]\" id=\"form-field-field_6c97db9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_12f9aa3 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12f9aa3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSecondary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_12f9aa3]\" id=\"form-field-field_12f9aa3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-30 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Email\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bc76778 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bc76778\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLegal Guardian Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bc76778]\" id=\"form-field-field_bc76778\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_41a0a79 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_41a0a79\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLegal Guardian Ralationship\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_41a0a79]\" id=\"form-field-field_41a0a79\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_3eb17b0 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3eb17b0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLegal Guardian Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_3eb17b0]\" id=\"form-field-field_3eb17b0\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_89476e4 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_89476e4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDocumentation?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_89476e4]\" id=\"form-field-field_89476e4\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b27dff9 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b27dff9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b27dff9]\" id=\"form-field-field_b27dff9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_f38675b elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f38675b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_f38675b]\" id=\"form-field-field_f38675b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ceda176 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ceda176\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSchool Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ceda176]\" id=\"form-field-field_ceda176\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_27c0dde elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_27c0dde\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGrade Level\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_27c0dde]\" id=\"form-field-field_27c0dde\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"PreK\">PreK<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kindergarden\">Kindergarden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1st Grade\">1st Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2nd Grade\">2nd Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3rd Grade\">3rd Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4th  Grade\">4th  Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5th Grade\">5th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6th Grade\">6th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7th Grade\">7th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8th Grade\">8th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9th Grade\">9th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10th Grade\">10th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11th Grade\">11th Grade<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12th Grade\">12th Grade<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9a9ded0 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9a9ded0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLanguage Preference\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9a9ded0]\" id=\"form-field-field_9a9ded0\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"English\">English<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish\">Spanish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Creole\">Creole<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4babaab elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4babaab\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRace\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4babaab]\" id=\"form-field-field_4babaab\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"White\">White<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"African-American\/Black\">African-American\/Black<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American Indian\">American Indian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Multi-Racial\">Multi-Racial<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Asian or Pacific Islander\">Asian or Pacific Islander<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_78b5486 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_78b5486\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEthnicity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_78b5486]\" id=\"form-field-field_78b5486\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Cuban\">Cuban<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mexican\">Mexican<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Puerto Rican\">Puerto Rican<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other Hispanic\">Other Hispanic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Haitian\">Haitian<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cb2c1af elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb2c1af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Provider\/ Medicaid\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cb2c1af]\" id=\"form-field-field_cb2c1af\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7b2d772 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b2d772\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance ID Number\/Medicaid #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7b2d772]\" id=\"form-field-field_7b2d772\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_39cd914 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_39cd914\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther Method of Payment\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Self-Pay\" id=\"form-field-field_39cd914-0\" name=\"form_fields[field_39cd914][]\"> <label for=\"form-field-field_39cd914-0\">Self-Pay<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pro-Bono\" id=\"form-field-field_39cd914-1\" name=\"form_fields[field_39cd914][]\"> <label for=\"form-field-field_39cd914-1\">Pro-Bono<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_29737ed elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_29737ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Care Physician (PCP) Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_29737ed]\" id=\"form-field-field_29737ed\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_522cc92 elementor-col-75\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_522cc92\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPCP Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_522cc92]\" id=\"form-field-field_522cc92\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_01cdbbf elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_01cdbbf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPCP City\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_01cdbbf]\" id=\"form-field-field_01cdbbf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_20c76a7 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_20c76a7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPCP State\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_20c76a7]\" id=\"form-field-field_20c76a7\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"AL\tAlabama\">AL\tAlabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AK\tAlaska\">AK\tAlaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\tArizona\">AZ\tArizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\tArkansas\">AR\tArkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\tCalifornia\">CA\tCalifornia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\tColorado\">CO\tColorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CT\tConnecticut\">CT\tConnecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\tDelaware\">DE\tDelaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DC\tDistrict Of Columbia\">DC\tDistrict Of Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FL\tFlorida\">FL\tFlorida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\tGeorgia\">GA\tGeorgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HI\tHawaii\">HI\tHawaii<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\tIdaho\">ID\tIdaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\tIllinois\">IL\tIllinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\tIndiana\">IN\tIndiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IA\tIowa\">IA\tIowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KS\tKansas\">KS\tKansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KY\tKentucky\">KY\tKentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\tLouisiana\">LA\tLouisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\tMaine\">ME\tMaine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\tMaryland\">MD\tMaryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\tMassachusetts\">MA\tMassachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MI\tMichigan\">MI\tMichigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\tMinnesota\">MN\tMinnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MS\tMississippi\">MS\tMississippi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MO\tMissouri\">MO\tMissouri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\tMontana\">MT\tMontana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\tNebraska\">NE\tNebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NV\tNevada\">NV\tNevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NH\tNew Hampshire\">NH\tNew Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NJ\tNew Jersey\">NJ\tNew Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NM\tNew Mexico\">NM\tNew Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NY\tNew York\">NY\tNew York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NC\tNorth Carolina\">NC\tNorth Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ND\tNorth Dakota\">ND\tNorth Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OH\tOhio\">OH\tOhio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OK\tOklahoma\">OK\tOklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OR\tOregon\">OR\tOregon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\tPennsylvania\">PA\tPennsylvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RI\tRhode Island\">RI\tRhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\tSouth Carolina\">SC\tSouth Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\tSouth Dakota\">SD\tSouth Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\tTennessee\">TN\tTennessee<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TX\tTexas\">TX\tTexas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UT\tUtah\">UT\tUtah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VT\tVermont\">VT\tVermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\tVirginia\">VA\tVirginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WA\tWashington\">WA\tWashington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WV\tWest Virginia\">WV\tWest Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WI\tWisconsin\">WI\tWisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WY\tWyoming\">WY\tWyoming<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AS   American Samoa\">AS   American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GU  Guam\">GU  Guam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MP  Northern Mariana Islands\">MP  Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PR   Puerto Rico\">PR   Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VI    US Virgin Islands\">VI    US Virgin Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DC   Washington, DC\">DC   Washington, DC<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_24cc614 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_24cc614\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPCP Zip Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_24cc614]\" id=\"form-field-field_24cc614\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_cb17810 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb17810\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPCP Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_cb17810]\" id=\"form-field-field_cb17810\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_8bb7425 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8bb7425\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPCP Fax Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_8bb7425]\" id=\"form-field-field_8bb7425\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_93a4353 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Decline in school functioning\" id=\"form-field-field_93a4353-0\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-0\">Decline in school functioning<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Decreased Grades\" id=\"form-field-field_93a4353-1\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-1\">Decreased Grades<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Poor Behavior\" id=\"form-field-field_93a4353-2\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-2\">Poor Behavior<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Poor School Attendance\" id=\"form-field-field_93a4353-3\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-3\">Poor School Attendance<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aggressive\/Disruptive Behavior\" id=\"form-field-field_93a4353-4\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-4\">Aggressive\/Disruptive Behavior<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Defiant\" id=\"form-field-field_93a4353-5\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-5\">Defiant<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Argumentative or Uncooperative\" id=\"form-field-field_93a4353-6\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-6\">Argumentative or Uncooperative<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fire Setting\" id=\"form-field-field_93a4353-7\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-7\">Fire Setting<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Arrested\" id=\"form-field-field_93a4353-8\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-8\">Arrested<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hyperactive\/Impulsive\" id=\"form-field-field_93a4353-9\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-9\">Hyperactive\/Impulsive<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Distracted\/Poor Focusing\" id=\"form-field-field_93a4353-10\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-10\">Distracted\/Poor Focusing<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anxiety\" id=\"form-field-field_93a4353-11\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-11\">Anxiety<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Irritability\" id=\"form-field-field_93a4353-12\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-12\">Irritability<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Worries\" id=\"form-field-field_93a4353-13\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-13\">Worries<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sad Mood\" id=\"form-field-field_93a4353-14\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-14\">Sad Mood<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Depression\" id=\"form-field-field_93a4353-15\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-15\">Depression<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sleep Problems\" id=\"form-field-field_93a4353-16\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-16\">Sleep Problems<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Social Isolation\" id=\"form-field-field_93a4353-17\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-17\">Social Isolation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Poor\/Increased Appetite\" id=\"form-field-field_93a4353-18\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-18\">Poor\/Increased Appetite<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mood Swings\" id=\"form-field-field_93a4353-19\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-19\">Mood Swings<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Intense Anger\" id=\"form-field-field_93a4353-20\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-20\">Intense Anger<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Emotional Outbursts\" id=\"form-field-field_93a4353-21\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-21\">Emotional Outbursts<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sucidial Ideation\" id=\"form-field-field_93a4353-22\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-22\">Sucidial Ideation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Homicidal Ideation\" id=\"form-field-field_93a4353-23\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-23\">Homicidal Ideation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sexual Abuse Victim\" id=\"form-field-field_93a4353-24\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-24\">Sexual Abuse Victim<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Schizophrenia\" id=\"form-field-field_93a4353-25\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-25\">Schizophrenia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hears Voices\" id=\"form-field-field_93a4353-26\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-26\">Hears Voices<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hallucinations\" id=\"form-field-field_93a4353-27\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-27\">Hallucinations<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Delusions\" id=\"form-field-field_93a4353-28\" name=\"form_fields[field_93a4353][]\"> <label for=\"form-field-field_93a4353-28\">Delusions<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_ddb6d2d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ddb6d2d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFamily Problems\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_ddb6d2d]\" id=\"form-field-field_ddb6d2d\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_591a120 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_591a120\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhobias (Describe)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_591a120]\" id=\"form-field-field_591a120\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_cbbbfd2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cbbbfd2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDanger to Self or Others (Describe)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_cbbbfd2]\" id=\"form-field-field_cbbbfd2\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_8adc9f5 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8adc9f5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInappropriate Sexual Behavior (Describe)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_8adc9f5]\" id=\"form-field-field_8adc9f5\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_2af27a8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2af27a8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDx of ID\/ASD\/Neurological Disorder (verbal\/nonverbal\/level of functioning)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_2af27a8]\" id=\"form-field-field_2af27a8\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_325c36b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_325c36b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSubstance Abuse (Describe current\/history of use)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_325c36b]\" id=\"form-field-field_325c36b\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_611c1fc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_611c1fc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMarchman\/Baker Act Recent History of (Dates Admitted\/Length of Stay)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_611c1fc]\" id=\"form-field-field_611c1fc\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_1c9b5cd elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c9b5cd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther (Describe)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_1c9b5cd]\" id=\"form-field-field_1c9b5cd\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ea3ea43 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ea3ea43\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTelehealth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_ea3ea43-0\" name=\"form_fields[field_ea3ea43][]\"> <label for=\"form-field-field_ea3ea43-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_ea3ea43-1\" name=\"form_fields[field_ea3ea43][]\"> <label for=\"form-field-field_ea3ea43-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_84d428c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_84d428c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs client currently involved with any agency\/mental health provider (DCF, DJJ, PO, JPO, PSY, etc.)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_84d428c-0\" name=\"form_fields[field_84d428c][]\"> <label for=\"form-field-field_84d428c-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_84d428c-1\" name=\"form_fields[field_84d428c][]\"> <label for=\"form-field-field_84d428c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0c038d6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0c038d6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, Providers name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0c038d6]\" id=\"form-field-field_0c038d6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_f1feb23 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f1feb23\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProviders Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_f1feb23]\" id=\"form-field-field_f1feb23\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_19abaee elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_19abaee\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReferring Agency\/School Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_19abaee]\" id=\"form-field-field_19abaee\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_48b48fd elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_48b48fd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStaff 's Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_48b48fd]\" id=\"form-field-field_48b48fd\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_9d9c8bf elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9d9c8bf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStaff Contact Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_9d9c8bf]\" id=\"form-field-field_9d9c8bf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres telef\u00f3nicos (#, -, *, etc.).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_215dcdf elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_215dcdf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStaff Email Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_215dcdf]\" id=\"form-field-field_215dcdf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-md\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>If this is an emergency, do not use this form This form is checked during office hours only. It is not monitored around the clock, and submitting it does not alert anyone immediately. 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