{"id":1351,"date":"2022-01-26T16:34:57","date_gmt":"2022-01-26T16:34:57","guid":{"rendered":"https:\/\/smhchhw.org\/?page_id=1351"},"modified":"2022-02-11T16:36:48","modified_gmt":"2022-02-11T16:36:48","slug":"appointment-request","status":"publish","type":"page","link":"https:\/\/smhchhw.org\/for-patients\/appointment-request\/","title":{"rendered":"Appointment Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1351\" class=\"elementor elementor-1351\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-91bc177 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"91bc177\" data-element_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-66 elementor-top-column elementor-element elementor-element-5fdf90a\" data-id=\"5fdf90a\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-975a742 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"975a742\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInDown&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.7.8 - 02-10-2022 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">If you are in an emergency situation or feel like you want to harm yourself or others, do not complete this form, instead seek immediate attention by calling one of the numbers below. <\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ef53da4 elementor-align-left elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-invisible elementor-widget elementor-widget-icon-list\" data-id=\"ef53da4\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;slideInLeft&quot;}\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<link rel=\"stylesheet\" href=\"https:\/\/smhchhw.org\/wp-content\/plugins\/elementor\/assets\/css\/widget-icon-list.min.css\">\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-phone-alt\"><use xlink:href=\"#fas-phone-alt\" \/><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">911<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-headphones\"><use xlink:href=\"#fas-headphones\" \/><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">National Suicide Prevention Lifeline: (800) 273-8255<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-phone-volume\"><use xlink:href=\"#fas-phone-volume\" \/><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">SAMSHA's National Helpline: (800) 662-HELP (4357)<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0cfe410 elementor-align-center animated-slow e-transform elementor-invisible elementor-widget elementor-widget-button\" data-id=\"0cfe410\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeIn&quot;,&quot;_transform_scale_effect_hover&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:1.2,&quot;sizes&quot;:[]},&quot;_transform_scale_effect_hover_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_scale_effect_hover_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a href=\"#\" class=\"elementor-button-link elementor-button elementor-size-sm\" role=\"button\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-text\">Additional Emergency Resources<\/span>\n\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6caa7f1 elementor-widget elementor-widget-spacer\" data-id=\"6caa7f1\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.7.8 - 02-10-2022 *\/\n.elementor-column .elementor-spacer-inner{height:var(--spacer-size)}.e-container{--container-widget-width:100%}.e-container>.elementor-widget-spacer{width:var(--container-widget-width,var(--spacer-size));-ms-flex-item-align:stretch;align-self:stretch;-ms-flex-negative:0;flex-shrink:0}.e-container>.elementor-widget-spacer>.elementor-widget-container,.e-container>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer{height:100%}.e-container>.elementor-widget-spacer>.elementor-widget-container>.elementor-spacer>.elementor-spacer-inner{height:var(--container-widget-height,var(--spacer-size))}<\/style>\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\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<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-c155b6e\" data-id=\"c155b6e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-bdd32b7 elementor-hidden-mobile elementor-invisible elementor-widget elementor-widget-image\" data-id=\"bdd32b7\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInRight&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.7.8 - 02-10-2022 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"600\" height=\"600\" src=\"https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Clouds.jpg\" class=\"attachment-large size-large\" alt=\"\" srcset=\"https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Clouds.jpg 600w, https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Clouds-300x300.jpg 300w, https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Clouds-150x150.jpg 150w\" sizes=\"(max-width: 600px) 100vw, 600px\" \/>\t\t\t\t\t\t\t\t\t\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\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a7b2f82 elementor-section-boxed elementor-section-height-default elementor-section-height-default elementor-invisible\" data-id=\"a7b2f82\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;slideInUp&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\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-154b8b9\" data-id=\"154b8b9\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6a2e4b3 elementor-widget elementor-widget-spacer\" data-id=\"6a2e4b3\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b7a15f8 elementor-widget elementor-widget-heading\" data-id=\"b7a15f8\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Healing for a Better Future.<\/h2>\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\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1e6b5a8 elementor-section-boxed elementor-section-height-default elementor-section-height-default elementor-invisible\" data-id=\"1e6b5a8\" data-element_type=\"section\" data-settings=\"{&quot;shape_divider_top&quot;:&quot;wave-brush&quot;,&quot;animation&quot;:&quot;slideInUp&quot;}\">\n\t\t\t\t\t<div class=\"elementor-shape elementor-shape-top\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 283.5 27.8\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" 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data-id=\"f36c82d\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;slideInLeft&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"600\" height=\"389\" src=\"https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Online-Form.jpg\" class=\"attachment-large size-large\" alt=\"\" srcset=\"https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Online-Form.jpg 600w, https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/01\/Online-Form-300x195.jpg 300w\" sizes=\"(max-width: 600px) 100vw, 600px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7e21ae8 elementor-blockquote--skin-quotation elementor-blockquote--button-color-official elementor-invisible elementor-widget elementor-widget-blockquote\" data-id=\"7e21ae8\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;slideInLeft&quot;}\" data-widget_type=\"blockquote.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor-pro - v3.8.1 - 07-11-2022 *\/\n@charset \"UTF-8\";.entry-content blockquote.elementor-blockquote:not(.alignright):not(.alignleft),.entry-summary blockquote.elementor-blockquote{margin-right:0;margin-left:0}.elementor-widget-blockquote blockquote{margin:0;padding:0;outline:0;font-size:100%;vertical-align:baseline;background:transparent;quotes:none;border:0;font-style:normal;color:#55595c}.elementor-widget-blockquote blockquote:after,.elementor-widget-blockquote blockquote:before,.elementor-widget-blockquote blockquote cite:after,.elementor-widget-blockquote blockquote cite:before,.elementor-widget-blockquote blockquote footer:after,.elementor-widget-blockquote blockquote 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i+span,.elementor-blockquote__tweet-button svg+span{margin-left:.5em}.elementor-blockquote__tweet-button svg{fill:#1da1f2;height:1em;width:1em}.elementor-blockquote__tweet-label{white-space:pre-wrap}.elementor-blockquote--button-skin-bubble .elementor-blockquote__tweet-button,.elementor-blockquote--button-skin-classic .elementor-blockquote__tweet-button{padding:.7em 1.2em;border-radius:100em;background-color:#1da1f2;color:#fff;font-size:15px}.elementor-blockquote--button-skin-bubble .elementor-blockquote__tweet-button:hover,.elementor-blockquote--button-skin-classic .elementor-blockquote__tweet-button:hover{background-color:#0967a0;color:#fff}.elementor-blockquote--button-skin-bubble .elementor-blockquote__tweet-button:hover:before,.elementor-blockquote--button-skin-classic .elementor-blockquote__tweet-button:hover:before{border-right-color:#0967a0}.elementor-blockquote--button-skin-bubble .elementor-blockquote__tweet-button svg,.elementor-blockquote--button-skin-classic .elementor-blockquote__tweet-button svg{fill:#fff;height:1em;width:1em}.elementor-blockquote--button-skin-bubble.elementor-blockquote--button-view-icon .elementor-blockquote__tweet-button,.elementor-blockquote--button-skin-classic.elementor-blockquote--button-view-icon .elementor-blockquote__tweet-button{padding:0;width:2em;height:2em}.elementor-blockquote--button-skin-bubble.elementor-blockquote--button-view-icon .elementor-blockquote__tweet-button i,.elementor-blockquote--button-skin-classic.elementor-blockquote--button-view-icon .elementor-blockquote__tweet-button i{position:absolute;left:50%;top:50%;-webkit-transform:translate(-50%,-50%);-ms-transform:translate(-50%,-50%);transform:translate(-50%,-50%)}.elementor-blockquote--button-skin-bubble .elementor-blockquote__tweet-button:before{content:\"\";border:.5em solid transparent;border-right-color:#1da1f2;position:absolute;left:-.8em;top:50%;-webkit-transform:translateY(-50%) scaleY(.65);-ms-transform:translateY(-50%) scaleY(.65);transform:translateY(-50%) scaleY(.65);-webkit-transition:.3s;-o-transition:.3s;transition:.3s}.elementor-blockquote--button-skin-bubble.elementor-blockquote--align-left .elementor-blockquote__tweet-button:before{right:auto;left:-.8em;border-right-color:#1da1f2;border-left-color:transparent}.elementor-blockquote--button-skin-bubble.elementor-blockquote--align-left .elementor-blockquote__tweet-button:hover:before{border-right-color:#0967a0}.elementor-blockquote--button-skin-bubble.elementor-blockquote--align-right .elementor-blockquote__tweet-button:before{left:auto;right:-.8em;border-right-color:transparent;border-left-color:#1da1f2}.elementor-blockquote--button-skin-bubble.elementor-blockquote--align-right .elementor-blockquote__tweet-button:hover:before{border-left-color:#0967a0}.elementor-blockquote--skin-boxed .elementor-blockquote{background-color:#e6e9ec;padding:30px}.elementor-blockquote--skin-border .elementor-blockquote{border-color:#e6e9ec;border-left:7px #e6e9ec;border-style:solid;padding-left:20px}.elementor-blockquote--skin-quotation .elementor-blockquote:before{content:\"\u201c\";font-size:100px;color:#e6e9ec;font-family:Times New Roman,Times,serif;font-weight:900;line-height:1;display:block;height:.6em}.elementor-blockquote--skin-quotation .elementor-blockquote__content{margin-top:15px}.elementor-blockquote--align-left .elementor-blockquote__content{text-align:left}.elementor-blockquote--align-left .elementor-blockquote footer{-webkit-box-orient:horizontal;-webkit-box-direction:normal;-ms-flex-direction:row;flex-direction:row}.elementor-blockquote--align-right .elementor-blockquote__content{text-align:right}.elementor-blockquote--align-right .elementor-blockquote footer{-webkit-box-orient:horizontal;-webkit-box-direction:reverse;-ms-flex-direction:row-reverse;flex-direction:row-reverse}.elementor-blockquote--align-center .elementor-blockquote{text-align:center}.elementor-blockquote--align-center .elementor-blockquote__author,.elementor-blockquote--align-center .elementor-blockquote footer{display:block}.elementor-blockquote--align-center .elementor-blockquote__tweet-button{margin-right:auto;margin-left:auto}<\/style>\t\t<blockquote class=\"elementor-blockquote\">\n\t\t\t<p class=\"elementor-blockquote__content\">\n\t\t\t\tOur goal is to be a safe landing spot for people that are struggling, find out what is best for each individual and help get him or her there.\t\t\t<\/p>\n\t\t\t\t\t\t\t<footer>\n\t\t\t\t\t\t\t\t\t\t\t<cite class=\"elementor-blockquote__author\">-Dr. Sarah B Scruggs, CEO of Arukah Institute of Healing & Lead Evaluator for Center for Holistic Health & Wellness<\/cite>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/footer>\n\t\t\t\t\t<\/blockquote>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2fca35b elementor-hidden-mobile elementor-widget elementor-widget-image\" data-id=\"2fca35b\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"500\" height=\"1677\" src=\"https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/02\/Beach-Side-Image.jpg\" class=\"attachment-full size-full\" alt=\"\" srcset=\"https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/02\/Beach-Side-Image.jpg 500w, https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/02\/Beach-Side-Image-89x300.jpg 89w, https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/02\/Beach-Side-Image-305x1024.jpg 305w, https:\/\/smhchhw.org\/wp-content\/uploads\/2022\/02\/Beach-Side-Image-458x1536.jpg 458w\" sizes=\"(max-width: 500px) 100vw, 500px\" \/>\t\t\t\t\t\t\t\t\t\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<div class=\"elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-87b4831\" data-id=\"87b4831\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d6e228b elementor-widget elementor-widget-spacer\" data-id=\"d6e228b\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2fd689b elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"2fd689b\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Online Appointment Request Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1fc64ce elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"1fc64ce\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.7.8 - 02-10-2022 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#818a91;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#818a91;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<h3>Your request is very important to us. If you are interested in services, please answer the following questions and someone will respond as soon as possible.\u00a0<\/h3><h3>If you are trying to schedule an appointment, all fields must be completed.<\/h3><p>**Please note that St. Margaret\u2019s Center for Holistic Health &amp; Wellness does not prescribe psychotropic medications.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9e79beb eael-gravity-form-button-custom elementor-invisible elementor-widget elementor-widget-eael-gravity-form\" data-id=\"9e79beb\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t            <div class=\"eael-contact-form eael-gravity-form eael-contact-form-align-default\">\n                                <script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme' id='gform_wrapper_1' style='display:none'>\n                        <div class='gform_heading'>\n                            <span class='gform_description'><\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/1351' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_30\"  class=\"gfield gfield--width-half hipaa_forms_first_name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_label' for='input_1_30' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_31\"  class=\"gfield gfield--width-half hipaa_forms_last_name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label' for='input_1_31' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_2\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><legend class='gfield_label gfield_label_before_complex'  >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_2' class='ginput_container ginput_complex'><div class='gfield_date_month ginput_container ginput_container_date' id='input_1_2_1_container'>\n                                            <input type='number'  name='input_2[]' id='input_1_2_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_2_1' class='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_1_2_2_container'>\n                                            <input type='number'  name='input_2[]' id='input_1_2_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_2_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_1_2_3_container'>\n                                            <input type='number'  name='input_2[]' id='input_1_2_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_1_2_3' class='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_3\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><legend class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_1_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_1_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_3_1' id='input_1_3_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_1_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_3_2' id='input_1_3_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_1_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_3_3' id='input_1_3_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_1_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_1_3_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_3_4' id='input_1_3_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_1_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_1_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_3_5' id='input_1_3_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_1_3_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_5\"  class=\"gfield gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label' for='input_1_5' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_6\"  class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><legend class='gfield_label gfield_label_before_complex'  >Is it okay if we leave a voice message at this phone number?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_6'><div class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Yes'  id='choice_1_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='No'  id='choice_1_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_2' id='label_1_6_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_7\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><label class='gfield_label' for='input_1_7' >Alternative Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_1_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_8\"  class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><legend class='gfield_label gfield_label_before_complex'  >Is it okay if we leave a voice message at this phone number?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_8'><div class='gchoice gchoice_1_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Yes'  id='choice_1_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_8_1' id='label_1_8_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='No'  id='choice_1_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_8_2' id='label_1_8_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_9\"  class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><legend class='gfield_label gfield_label_before_complex'  >When is the best time to contact you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_9'><div class='gchoice gchoice_1_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Early Morning'  id='choice_1_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1'>Early Morning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Mid\/Late Morning'  id='choice_1_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_2' id='label_1_9_2'>Mid\/Late Morning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Afternoon'  id='choice_1_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_3' id='label_1_9_3'>Afternoon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Evening'  id='choice_1_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_4' id='label_1_9_4'>Evening<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Other'  id='choice_1_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_5' id='label_1_9_5'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_10\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label' for='input_1_10' >Best time to contact you if you selected &quot;other&quot; for previous question:<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_29\"  class=\"gfield gfield--width-full hipaa_forms_email field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label' for='input_1_29' >Email<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_11\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><label class='gfield_label' for='input_1_11' >Health Insurance Provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_12\"  class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><label class='gfield_label' for='input_1_12' >Primary Care Provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_13\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><label class='gfield_label' for='input_1_13' >Referred By<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_14\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><label class='gfield_label' for='input_1_14' >Current Problem\/Situation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea large'  aria-describedby=\"gfield_description_1_14\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_14'>Please provide brief description of why you are requesting an appointment. <\/div><\/div><fieldset id=\"field_1_16\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><legend class='gfield_label'  >Please list any current or previous diagnoses (if known)<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group'><div class='gfield_list_group_item gfield_list_cell gfield_list_16_cell1' ><input aria-invalid='false'   aria-label='Please list any current or previous diagnoses (if known), Row 1' data-aria-label-template='Please list any current or previous diagnoses (if known), Row {0}' type='text' name='input_16[]' value=''   \/><\/div><div class='gfield_list_icons'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_18\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><legend class='gfield_label gfield_label_before_complex'  >Are you currently experiencing (check all that apply):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_18'><div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Depression'  id='choice_1_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Anxiety'  id='choice_1_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Trauma'  id='choice_1_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_3' id='label_1_18_3'>Trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Anger Problems'  id='choice_1_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_4' id='label_1_18_4'>Anger Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Sleep Disturbances'  id='choice_1_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_5' id='label_1_18_5'>Sleep Disturbances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='Suicidal Thoughts'  id='choice_1_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_6' id='label_1_18_6'>Suicidal Thoughts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.7' type='checkbox'  value='Homicidal Thoughts'  id='choice_1_18_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_7' id='label_1_18_7'>Homicidal Thoughts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.8' type='checkbox'  value='Substance Abuse'  id='choice_1_18_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_8' id='label_1_18_8'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><legend class='gfield_label gfield_label_before_complex'  >If any of the above problems were identified, how difficult have these made it for you to do your work, take care of things at home or get along with other people?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_20'><div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Not difficult at all'  id='choice_1_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1'>Not difficult at all<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Somewhat difficult'  id='choice_1_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2'>Somewhat difficult<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Very difficult'  id='choice_1_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3'>Very difficult<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Extremely difficult'  id='choice_1_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_4' id='label_1_20_4'>Extremely difficult<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='No problems identified'  id='choice_1_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_5' id='label_1_20_5'>No problems identified<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_21\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><legend class='gfield_label gfield_label_before_complex'  >Preferred Appointment Times (Subject to availability of therapist)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_21'><div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Morning (9am - 11am)'  id='choice_1_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1'>Morning (9am - 11am)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Afternoon (12pm - 2pm)'  id='choice_1_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2'>Afternoon (12pm - 2pm)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Late Afternoon (3pm - 4pm)'  id='choice_1_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_3' id='label_1_21_3'>Late Afternoon (3pm - 4pm)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Early Evening (5pm - 6pm)'  id='choice_1_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_4' id='label_1_21_4'>Early Evening (5pm - 6pm)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Any'  id='choice_1_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_5' id='label_1_21_5'>Any<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><legend class='gfield_label gfield_label_before_complex'  >Preferred Appointment Days (Subject to availability of therapist)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_22'><div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Monday'  id='choice_1_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1'>Monday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Tuesday'  id='choice_1_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_2' id='label_1_22_2'>Tuesday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Wednesday'  id='choice_1_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_3' id='label_1_22_3'>Wednesday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Thursday'  id='choice_1_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_4' id='label_1_22_4'>Thursday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Friday'  id='choice_1_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_5' id='label_1_22_5'>Friday<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_23\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><legend class='gfield_label gfield_label_before_complex'  >Preferred Location (Subject to availability of therapist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_23'><div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Arukah Institute of Healing (Princeton)'  id='choice_1_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1'>Arukah Institute of Healing (Princeton)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Center for Holistic Health &amp; Wellness (Spring Valley Satellite Office)'  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2'>Center for Holistic Health & Wellness (Spring Valley Satellite Office)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Center for Holistic Health &amp; Wellness (Peru Satellite Office)'  id='choice_1_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3'>Center for Holistic Health & Wellness (Peru Satellite Office)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_24\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><legend class='gfield_label gfield_label_before_complex'  >Preferred Appointment Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='In Office'  id='choice_1_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1'>In Office<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Telehealth\/ Virtual Session Using Your Computer, Tablet or Phone'  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2'>Telehealth\/ Virtual Session Using Your Computer, Tablet or Phone<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_25\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><H4>PLEASE NOTE:<\/H4>\n\n<p>\n<strong>Telehealth may NOT be the best option for you if you can answer \"yes\" to any of the following:<\/strong>\n\n<ul>\n  <li>You have thoughts of hurting yourself or others<\/li>\n  <li>You are a minor or you are under the care of a legal guardian<\/li>\n  <li>You are in an urgent crisis or an emergency situation <\/li>\n  <li>You have been diagnosed with a severe mental illness, or if you have been advised to be in psychological supervision or psychiatric care<\/li>\n  <li>You were required to undergo therapy or counseling either by a court order or by any other authority <\/li>\n  <li>You do not have a device that can connect to the internet or you do not have a reliable internet connection<\/li>\n<\/ul><\/p><\/div><fieldset id=\"field_1_27\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><legend class='gfield_label gfield_label_before_complex'  >Would you like to request accommodation?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_27'><div class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Yes'  id='choice_1_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='No'  id='choice_1_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_2' id='label_1_27_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_28\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><label class='gfield_label' for='input_1_28' >Is there any additional information you&#039;d like to provide?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_1_28' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'>  \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjM4YTY3ZTBlNjNlNGM0YzdiMWVlYmYzYzkzNWIwNTc0Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>            <\/div>\n            \t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9bdf0b9 elementor-widget elementor-widget-spacer\" data-id=\"9bdf0b9\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\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\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>If you are in an emergency situation or feel like you want to harm yourself or others, do not complete this form, instead seek immediate attention by calling one of the numbers below. 911 National Suicide Prevention Lifeline: (800) 273-8255 SAMSHA&#8217;s National Helpline: (800) 662-HELP (4357) Additional Emergency Resources Healing for a Better Future. Our [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":1352,"parent":949,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_theme","meta":[],"_links":{"self":[{"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/pages\/1351"}],"collection":[{"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/comments?post=1351"}],"version-history":[{"count":5,"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/pages\/1351\/revisions"}],"predecessor-version":[{"id":2016,"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/pages\/1351\/revisions\/2016"}],"up":[{"embeddable":true,"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/pages\/949"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/media\/1352"}],"wp:attachment":[{"href":"https:\/\/smhchhw.org\/wp-json\/wp\/v2\/media?parent=1351"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}