{"id":7,"date":"2018-11-27T09:17:42","date_gmt":"2018-11-27T09:17:42","guid":{"rendered":"http:\/\/mercybehavioralhealthcenter.com\/?page_id=7"},"modified":"2023-03-10T00:30:52","modified_gmt":"2023-03-10T00:30:52","slug":"referrals","status":"publish","type":"page","link":"https:\/\/mercybehavioralhealthcenter.com\/?page_id=7","title":{"rendered":"Referrals"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"7\" class=\"elementor elementor-7\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7ac9ca5 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7ac9ca5\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&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-90988fe\" data-id=\"90988fe\" 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-4a1c612 elementor-widget elementor-widget-heading\" data-id=\"4a1c612\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.9.2 - 21-12-2022 *\/\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><h1 class=\"elementor-heading-title elementor-size-default\">REFERRAL<\/h1>\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-2958c1d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2958c1d\" 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-100 elementor-top-column elementor-element elementor-element-3ae5375\" data-id=\"3ae5375\" 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-6432a9d elementor-widget elementor-widget-heading\" data-id=\"6432a9d\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Online Referral Form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-87a0815 elementor-widget elementor-widget-shortcode\" data-id=\"87a0815\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container \" id=\"wpforms-25290\"><form id=\"wpforms-form-25290\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"25290\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F7\" data-token=\"0d8bfd4f40b74a13443539aac87d0d36\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-25290-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_1\">Your Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-25290-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-25290-field_1\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-25290-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-25290-field_1-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-25290-field_2-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_2\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-25290-field_2\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_2_1\" name=\"wpforms[fields][2][]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_2_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_2_2\" name=\"wpforms[fields][2][]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_2_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-25290-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_3\">Legal guardian of client, if a minor<\/label><input type=\"text\" id=\"wpforms-25290-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-25290-field_4-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_4\">Marital Status  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-25290-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_4_1\" name=\"wpforms[fields][4][]\" value=\"Single\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_4_1\">Single<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_4_2\" name=\"wpforms[fields][4][]\" value=\"Engaged\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_4_2\">Engaged<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_4_3\" name=\"wpforms[fields][4][]\" value=\"Married\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_4_3\">Married<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_4_4\" name=\"wpforms[fields][4][]\" value=\"Divorced\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_4_4\">Divorced<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_4_5\" name=\"wpforms[fields][4][]\" value=\"Widowed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_4_5\">Widowed<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_4_6\" name=\"wpforms[fields][4][]\" value=\"Separated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_4_6\">Separated<\/label><\/li><\/ul><\/div><div id=\"wpforms-25290-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_8\">SSN <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_8\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-25290-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_9\">Date Of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_9\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-25290-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_10\">Street Address  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-25290-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_11\">Race <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_11\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-25290-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_12\">Cell Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_12\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-25290-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_13\">Home Phone  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_13\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][13]\" required><\/div><div id=\"wpforms-25290-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_14\">Work Phone  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_14\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><div id=\"wpforms-25290-field_5-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_5\">Insurance  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-25290-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-25290-field_5_1\" name=\"wpforms[fields][5][]\" value=\"Medicare\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-25290-field_5_1\">Medicare<\/label><\/li><\/ul><\/div><div id=\"wpforms-25290-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_6\">Medical Assistant # <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-25290-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-25290-field_7\">Other Insurance <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-25290-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><\/div><div class=\"wpforms-submit-container\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"25290\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-25290\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/mercybehavioralhealthcenter.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/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>REFERRAL Online Referral Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-global-header-display":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"enabled","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","footnotes":""},"class_list":["post-7","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=\/wp\/v2\/pages\/7","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=7"}],"version-history":[{"count":14,"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=\/wp\/v2\/pages\/7\/revisions"}],"predecessor-version":[{"id":25331,"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=\/wp\/v2\/pages\/7\/revisions\/25331"}],"wp:attachment":[{"href":"https:\/\/mercybehavioralhealthcenter.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=7"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}