{"id":2302,"date":"2023-10-04T09:40:44","date_gmt":"2023-10-04T09:40:44","guid":{"rendered":"http:\/\/72.52.251.108\/~woodlandspsych\/?page_id=2302"},"modified":"2023-10-04T11:37:10","modified_gmt":"2023-10-04T11:37:10","slug":"new-patient-request-an-appointment","status":"publish","type":"page","link":"http:\/\/72.52.251.108\/~woodlandspsych\/new-patient-request-an-appointment\/","title":{"rendered":"New Patient Request an Appointment"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1365px;margin-left: calc(-5% \/ 2 );margin-right: calc(-5% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.375%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.375%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:2.375%;--awb-spacing-left-medium:2.375%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-2301\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-form-input-height:40px;--awb-form-bg-color:var(--awb-color3);--awb-form-font-size:18px;--awb-form-placeholder-color:var(--awb-color6);--awb-form-text-color:var(--awb-color8);--awb-form-label-color:var(--awb-color6);--awb-form-border-color:var(--awb-color4);--awb-form-focus-border-color:var(--awb-color5);--awb-form-focus-border-hover-color:hsla(var(--awb-color5-h),var(--awb-color5-s),var(--awb-color5-l),calc(var(--awb-color5-a) - 50%));--awb-form-border-radius:0px;\" data-form-id=\"2301\" data-config=\"{&quot;form_id&quot;:&quot;2301&quot;,&quot;form_post_id&quot;:&quot;2301&quot;,&quot;post_id&quot;:2302,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;message_details&quot;:&quot;Message Details&quot;,&quot;patient- first-name&quot;:&quot;Patient First Name&quot;,&quot;last-name&quot;:&quot;Patient Last Name&quot;,&quot;parentguardian_name&quot;:&quot;Parent\\\/Guardian Name&quot;,&quot;phone&quot;:&quot;Phone (123-456-7890)&quot;,&quot;email&quot;:&quot;Email address&quot;,&quot;date_of_birth&quot;:&quot;Date of Birth&quot;,&quot;select_specialty&quot;:&quot;Select Specialty&quot;,&quot;insurance_provider&quot;:&quot;Insurance Provider&quot;,&quot;insurance-id&quot;:&quot;Insurance ID&quot;,&quot;insurance_subscriber_full_name&quot;:&quot;Insurance Subscriber Full Name&quot;,&quot;subscriber-date-of-birth&quot;:&quot;Subscriber Date of Birth&quot;,&quot;upload_front_of_insurance_card_image_only&quot;:&quot;Upload Front &amp; Back of Insurance Card (Image Only)&quot;,&quot;what_brings_you_here&quot;:&quot;What Brings You Here?&quot;,&quot;were_you_referred_here_if_so_by_who&quot;:&quot;Were you referred here? If so, by who?&quot;},&quot;field_logics&quot;:{&quot;message_details&quot;:&quot;&quot;,&quot;patient- first-name&quot;:&quot;&quot;,&quot;last-name&quot;:&quot;&quot;,&quot;parentguardian_name&quot;:&quot;&quot;,&quot;phone&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;date_of_birth&quot;:&quot;&quot;,&quot;select_specialty&quot;:&quot;&quot;,&quot;insurance_provider&quot;:&quot;&quot;,&quot;insurance-id&quot;:&quot;&quot;,&quot;insurance_subscriber_full_name&quot;:&quot;&quot;,&quot;subscriber-date-of-birth&quot;:&quot;&quot;,&quot;upload_front_of_insurance_card_image_only&quot;:&quot;&quot;,&quot;what_brings_you_here&quot;:&quot;&quot;,&quot;were_you_referred_here_if_so_by_who&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;message_details&quot;:&quot;textarea&quot;,&quot;patient- first-name&quot;:&quot;text&quot;,&quot;last-name&quot;:&quot;text&quot;,&quot;parentguardian_name&quot;:&quot;text&quot;,&quot;phone&quot;:&quot;phone_number&quot;,&quot;email&quot;:&quot;email&quot;,&quot;date_of_birth&quot;:&quot;date&quot;,&quot;select_specialty&quot;:&quot;checkbox&quot;,&quot;insurance_provider&quot;:&quot;checkbox&quot;,&quot;insurance-id&quot;:&quot;text&quot;,&quot;insurance_subscriber_full_name&quot;:&quot;text&quot;,&quot;subscriber-date-of-birth&quot;:&quot;date&quot;,&quot;upload_front_of_insurance_card_image_only&quot;:&quot;upload&quot;,&quot;what_brings_you_here&quot;:&quot;text&quot;,&quot;were_you_referred_here_if_so_by_who&quot;:&quot;text&quot;,&quot;submit_1&quot;:&quot;submit&quot;,&quot;notice_1&quot;:&quot;notice&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;}\"><form action=\"http:\/\/72.52.251.108\/~woodlandspsych\/new-patient-request-an-appointment\/\" method=\"post\" class=\"fusion-form fusion-form-2301\" enctype=\"multipart\/form-data\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:50px;--awb-padding-bottom:50px;--awb-background-color:#ffffff;--awb-flex-wrap:wrap;\" ><div class=\"awb-background-mask\" style=\"background-image:  url(data:image\/svg+xml;utf8,%3Csvg%20width%3D%221920%22%20height%3D%22954%22%20fill%3D%22none%22%20xmlns%3D%22http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg%22%3E%3Cg%20clip-path%3D%22url%28%23prefix__clip0_58_894%29%22%3E%3Cpath%20stroke%3D%22rgba%28239%2C71%2C111%2C1%29%22%20stroke-width%3D%22120%22%20d%3D%22M1345%20600.853l353.553%20353.553L1345%201307.96%20991.447%20954.406z%22%2F%3E%3Cpath%20stroke%3D%22rgba%28239%2C71%2C111%2C1%29%22%20stroke-width%3D%2260%22%20d%3D%22M1345%20815.426L1633.574%201104%201345%201392.574%201056.426%201104z%22%2F%3E%3Cpath%20fill%3D%22rgba%28239%2C71%2C111%2C1%29%22%20d%3D%22M1345-439L1783.406-.594%201345%20437.812%20906.594-.594z%22%2F%3E%3Cpath%20stroke%3D%22rgba%28239%2C71%2C111%2C1%29%22%20stroke-width%3D%22240%22%20d%3D%22M1921.76%20168.706l309.059%20309.059-309.059%20309.058-309.059-309.058z%22%2F%3E%3C%2Fg%3E%3Cdefs%3E%3CclipPath%20id%3D%22prefix__clip0_58_894%22%3E%3Cpath%20fill%3D%22%23fff%22%20d%3D%22M0%200h1920v954H0z%22%2F%3E%3C%2FclipPath%3E%3C%2Fdefs%3E%3C%2Fsvg%3E);opacity: 0.05 ;transform: scale(1, 1);mix-blend-mode:normal;\"><\/div><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"width:105% !important;max-width:105% !important;margin-left: calc(-5% \/ 2 );margin-right: calc(-5% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_5_6 5_6 fusion-flex-column\" style=\"--awb-padding-top:50px;--awb-padding-right:50px;--awb-padding-bottom:50px;--awb-padding-left:50px;--awb-overflow:hidden;--awb-bg-color:#ffffff;--awb-bg-color-hover:#ffffff;--awb-bg-size:cover;--awb-box-shadow:0px 2px 25px 15px rgba(0,0,0,0.05);;--awb-border-radius:5px 5px 5px 5px;--awb-width-large:83.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.85%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.85%;--awb-width-medium:83.333333333333%;--awb-order-medium:0;--awb-spacing-right-medium:2.85%;--awb-spacing-left-medium:2.85%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#022835;--awb-margin-top:0px;--awb-margin-bottom:20px;--awb-font-size:48px;\"><h1 class=\"fusion-title-heading title-heading-center\" style=\"font-family:&quot;Montserrat&quot;;font-style:normal;font-weight:300;margin:0;font-size:1em;text-transform:capitalize;line-height:1.5;\">New Patient Appointment<\/h1><\/div><div class=\"fusion-text fusion-text-1 fusion-text-no-margin\" style=\"--awb-content-alignment:center;--awb-font-size:20px;--awb-line-height:1.2;--awb-letter-spacing:0px;--awb-text-transform:var(--awb-typography2-text-transform);--awb-text-color:var(--awb-color7);--awb-margin-bottom:30px;--awb-text-font-family:&quot;Montserrat&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\"><p>WE ARE CURRENTLY ONLY ACCEPTING NEW PATIENT APPOINTMENT<br \/>\nREQUESTS ONLINE. PLEASE FILL OUT FORM IN ENTIRETY<\/p>\n<\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"width:105% !important;max-width:105% !important;margin-left: calc(-5% \/ 2 );margin-right: calc(-5% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.375%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.375%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:2.375%;--awb-spacing-left-medium:2.375%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><label for=\"message_details\">Message Details <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"message_details\" name=\"message_details\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-1 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"patient- first-name\">Patient First Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"patient- first-name\" id=\"patient- first-name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-2 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"last-name\">Patient Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"last-name\" id=\"last-name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-3 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"parentguardian_name\">Parent\/Guardian Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"parentguardian_name\" id=\"parentguardian_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-4 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"phone\">Phone (123-456-7890) <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"tel\" name=\"phone\" id=\"phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-5 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"email\">Email address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"email\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"example@domain.com*\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-6 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><label for=\"date_of_birth\">Date of Birth<\/label><input autocomplete=\"no\" type=\"date\" data-first-day=\"1\"  data-format=\"\" tabindex=\"\" id=\"date_of_birth\" name=\"date_of_birth\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\"autocomplete=\"no\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-7 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Select Specialty<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-select_specialty-1-0\" type=\"checkbox\" value=\"Psychiatrist\" name=\"select_specialty[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-select_specialty-1-0\">Psychiatrist<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-select_specialty-1-1\" type=\"checkbox\" value=\"TMS\" name=\"select_specialty[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-select_specialty-1-1\">TMS<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-select_specialty-1-2\" type=\"checkbox\" value=\"Clinical Trials\" name=\"select_specialty[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-select_specialty-1-2\">Clinical Trials<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-8 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Insurance Provider<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-insurance_provider-2-0\" type=\"checkbox\" value=\"Self-Pay\" name=\"insurance_provider[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-insurance_provider-2-0\">Self-Pay<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-insurance_provider-2-1\" type=\"checkbox\" value=\"Other\" name=\"insurance_provider[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-insurance_provider-2-1\">Other<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-9 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"insurance-id\">Insurance ID<\/label><\/div><input type=\"text\" name=\"insurance-id\" id=\"insurance-id\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-10 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"insurance_subscriber_full_name\">Insurance Subscriber Full Name<\/label><\/div><input type=\"text\" name=\"insurance_subscriber_full_name\" id=\"insurance_subscriber_full_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-11 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.375%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.375%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:2.375%;--awb-spacing-left-medium:2.375%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><label for=\"subscriber-date-of-birth\">Subscriber Date of Birth<\/label><input autocomplete=\"no\" type=\"date\" data-first-day=\"1\"  data-format=\"\" tabindex=\"\" id=\"subscriber-date-of-birth\" name=\"subscriber-date-of-birth\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\"autocomplete=\"no\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-12 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.375%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.375%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:2.375%;--awb-spacing-left-medium:2.375%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2 fusion-text-no-margin\" style=\"--awb-content-alignment:center;--awb-font-size:18px;--awb-line-height:1.5;--awb-letter-spacing:0px;--awb-text-transform:uppercase;--awb-text-color:#022835;--awb-margin-bottom:20px;--awb-text-font-family:&quot;Montserrat&quot;;--awb-text-font-style:normal;--awb-text-font-weight:500;\"><p>Only Requests with an insurance card can be considered<\/p>\n<\/div><div class=\"fusion-form-field fusion-form-upload-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><label for=\"upload_front_of_insurance_card_image_only\">Upload Front &amp; Back of Insurance Card (Image Only)<\/label><div class=\"fusion-form-input-with-icon\"><i class=\" fa-upload fas\"><\/i><div class=\"fusion-form-upload-field-container\"><input type=\"file\" id=\"upload_front_of_insurance_card_image_only\" name=\"upload_front_of_insurance_card_image_only[]\" value=\"\"  class=\"fusion-form-input\"accept=\".jpg,.png,.doc,.docs,.pdf\" placeholder=\"Click or drag a file to this area to upload.\" data-size=\"15\" multiple\/><input type=\"text\" disabled value=\"\" class=\"fusion-form-upload-field\"  placeholder=\"Click or drag a file to this area to upload.\" data-holds-private-data=\"false\"\/><div ><a class=\"fusion-button button-flat button-medium button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button\" style=\"--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;\" target=\"_self\" href=\"javascript:void();\"><span class=\"fusion-button-text\">Choose File<\/span><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-13 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"what_brings_you_here\">What Brings You Here?<\/label><\/div><input type=\"text\" name=\"what_brings_you_here\" id=\"what_brings_you_here\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-14 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.75%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:4.75%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:4.75%;--awb-spacing-left-medium:4.75%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div class=\"fusion-form-label-wrapper\"><label for=\"were_you_referred_here_if_so_by_who\">Were you referred here? If so, by who?<\/label><\/div><input type=\"text\" name=\"were_you_referred_here_if_so_by_who\" id=\"were_you_referred_here_if_so_by_who\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-15 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.375%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.375%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:2.375%;--awb-spacing-left-medium:2.375%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-spacing-left-small:2.375%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"2301\"><div style=\"text-align:center;\"><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-custom fusion-button-default button-2 fusion-button-span-yes  form-form-submit button-default\" style=\"--button_accent_color:#ffffff;--button_accent_hover_color:#ffffff;--button_border_hover_color:var(--awb-color1);--button-border-radius-top-left:0px;--button-border-radius-top-right:0px;--button-border-radius-bottom-right:0px;--button-border-radius-bottom-left:0px;--button_gradient_top_color:var(--awb-color8);--button_gradient_bottom_color:var(--awb-color8);--button_gradient_top_color_hover:#326779;--button_gradient_bottom_color_hover:#326779;--button_text_transform:capitalize;--button_font_size:20px;--button_line_height:1.2;--button_padding-top:20px;--button_padding-bottom:20px;--button_typography-letter-spacing:0px;--button_typography-font-family:&quot;Montserrat&quot;;--button_typography-font-style:normal;--button_typography-font-weight:500;--button_margin-top:10px;\" data-form-number=\"2301\" tabindex=\"\"><span class=\"fusion-button-text\">SUBMIT<\/span><\/button><\/div><\/div><\/div><\/div><\/div><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. It has been sent.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"content-type":"","footnotes":""},"class_list":["post-2302","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/pages\/2302","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/comments?post=2302"}],"version-history":[{"count":3,"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/pages\/2302\/revisions"}],"predecessor-version":[{"id":2306,"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/pages\/2302\/revisions\/2306"}],"wp:attachment":[{"href":"http:\/\/72.52.251.108\/~woodlandspsych\/wp-json\/wp\/v2\/media?parent=2302"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}