{"id":2705,"date":"2025-12-11T06:45:42","date_gmt":"2025-12-10T19:45:42","guid":{"rendered":"https:\/\/yoursolace.com\/?page_id=2705"},"modified":"2025-12-11T06:45:42","modified_gmt":"2025-12-10T19:45:42","slug":"referral","status":"publish","type":"page","link":"https:\/\/yoursolace.com\/index.php\/referral\/","title":{"rendered":"Referral"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-2704 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2704\" data-uid=\"6a1edabfcd850\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2704\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2704 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"2704\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a1edabfcd850\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Ready To Get Started?<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid #e25d8b;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><select  id=\"forminator-form-2704__field--select-1_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-1_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Myself as the participant<\/option><option value=\"two\"  data-calculation=\"0\">Someone I am referring to Australian Care Well Services<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-2\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Participant Details<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid #e25d8b;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a1edabfcd850\" id=\"forminator-field-name-1_6a1edabfcd850-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"Participant Details\" id=\"forminator-field-name-1_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a1edabfcd850\" id=\"forminator-field-name-2_6a1edabfcd850-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"Participant Details\" id=\"forminator-field-name-2_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a1edabfcd850\" id=\"forminator-field-date-1-picker_6a1edabfcd850-label\" class=\"forminator-label\">D.O.B <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_6a1edabfcd850\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-2_6a1edabfcd850\" id=\"forminator-form-2704__field--select-2_6a1edabfcd850-label\" class=\"forminator-label\">Gender<\/label><select  id=\"forminator-form-2704__field--select-2_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-2_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Male<\/option><option value=\"two\"  data-calculation=\"0\">Female<\/option><option value=\"custom_option\"  data-calculation=\"0\">Other<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-2704__field--select-2_6a1edabfcd850\" name=\"custom-select-2\" class=\"forminator-input\" aria-label=\"Other\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a1edabfcd850\" id=\"forminator-field-address-1-street_address_6a1edabfcd850-label\" class=\"forminator-label\">Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a1edabfcd850\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a1edabfcd850\" id=\"forminator-field-phone-1_6a1edabfcd850-label\" class=\"forminator-label\">Participant Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a1edabfcd850\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a1edabfcd850\" id=\"forminator-field-email-1_6a1edabfcd850-label\" class=\"forminator-label\">Participant Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a1edabfcd850\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6a1edabfcd850\" id=\"forminator-field-name-3_6a1edabfcd850-label\" class=\"forminator-label\">Participant NDIS Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a1edabfcd850-label\"><span id=\"forminator-radiogroup-radio-1-6a1edabfcd850-label\" class=\"forminator-label\">Does The Participant Have A Legal Guardian \/ Nominee? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a1edabfcd850\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a1edabfcd850\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a1edabfcd850\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a1edabfcd850\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-3\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Cultural Details<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid 1;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_6a1edabfcd850\" id=\"forminator-field-name-4_6a1edabfcd850-label\" class=\"forminator-label\">Participant Country Of Birth <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-3_6a1edabfcd850\" id=\"forminator-form-2704__field--select-3_6a1edabfcd850-label\" class=\"forminator-label\">Does The Participant Require An Interpreter? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-3_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-3_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Yes<\/option><option value=\"two\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_6a1edabfcd850\" id=\"forminator-field-name-5_6a1edabfcd850-label\" class=\"forminator-label\">Relevant Culture Or Religious Considerations(If Any)? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-4_6a1edabfcd850\" id=\"forminator-form-2704__field--select-4_6a1edabfcd850-label\" class=\"forminator-label\">Does The Listed Participant Identify As An Aboriginal Or Torres Strait Islander? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-4_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-4\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-4_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Option 1<\/option><option value=\"two\"  data-calculation=\"0\">Option 2<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-4\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Services Request<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-5_6a1edabfcd850\" id=\"forminator-form-2704__field--select-5_6a1edabfcd850-label\" class=\"forminator-label\">Type Of Primary Service Required: <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-5_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-5\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-5_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Personal Care<\/option><option value=\"two\"  data-calculation=\"0\">Community Access<\/option><option value=\"Domestic\"  data-calculation=\"0\">Domestic Assistance<\/option><option value=\"Cleaning-and-Gardening-Services\"  data-calculation=\"0\">Cleaning and Gardening Services<\/option><option value=\"Supported-Independent-Living\"  data-calculation=\"0\">Supported Independent Living<\/option><option value=\"Group-Activities\"  data-calculation=\"0\">Group Activities<\/option><option value=\"custom_option\"  data-calculation=\"0\">Other<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-2704__field--select-5_6a1edabfcd850\" name=\"custom-select-5\" class=\"forminator-input\" aria-label=\"Other\" value=\"\" \/><\/div><\/div><\/div><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_6a1edabfcd850\" id=\"forminator-field-name-6_6a1edabfcd850-label\" class=\"forminator-label\">Number Of Hours Requested For Service: <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-6_6a1edabfcd850\" id=\"forminator-form-2704__field--select-6_6a1edabfcd850-label\" class=\"forminator-label\">Type Of Secondary Service Required: <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-6_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-6\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-6_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Personal Care<\/option><option value=\"two\"  data-calculation=\"0\">Community Access<\/option><option value=\"Domestic-Assistance\"  data-calculation=\"0\">Domestic Assistance<\/option><option value=\"Cleaning-And-Gardening-Services\"  data-calculation=\"0\">Cleaning And Gardening Services<\/option><option value=\"Supported\"  data-calculation=\"0\">Supported Independent Living<\/option><option value=\"Group-Activies\"  data-calculation=\"0\">Group Activities<\/option><option value=\"custom_option\"  data-calculation=\"0\">Other<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-2704__field--select-6_6a1edabfcd850\" name=\"custom-select-6\" class=\"forminator-input\" aria-label=\"Other\" value=\"\" \/><\/div><\/div><\/div><div id=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-7_6a1edabfcd850\" id=\"forminator-form-2704__field--select-7_6a1edabfcd850-label\" class=\"forminator-label\">Additional Service Required: <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-7_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-7\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-7_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Personal Care<\/option><option value=\"two\"  data-calculation=\"0\">Community Access<\/option><option value=\"Domestic-Assistance\"  data-calculation=\"0\">Domestic Assistance<\/option><option value=\"Cleaning-And-Gardening-Services\"  data-calculation=\"0\">Cleaning And Gardening Services<\/option><option value=\"Supported\"  data-calculation=\"0\">Supported Independent Living<\/option><option value=\"Group-Activies\"  data-calculation=\"0\">Group Activities<\/option><option value=\"custom_option\"  data-calculation=\"0\">Other<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-2704__field--select-7_6a1edabfcd850\" name=\"custom-select-7\" class=\"forminator-input\" aria-label=\"Other\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a1edabfcd850\" id=\"forminator-field-text-1_6a1edabfcd850-label\" class=\"forminator-label\">Participant&#039;s Relevant Conditions \/ Disability (Please List):<\/label><span id=\"forminator-field-text-1_6a1edabfcd850-description\" class=\"forminator-description\"><span data-limit=\"8000\" data-type=\"words\">0 \/ 8000<\/span><\/span><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a1edabfcd850\" id=\"forminator-field-text-2_6a1edabfcd850-label\" class=\"forminator-label\">Extra Information That May Assist With Preparation For Initial Appointment:<\/label><span id=\"forminator-field-text-2_6a1edabfcd850-description\" class=\"forminator-description\"><span data-limit=\"8000\" data-type=\"words\">0 \/ 8000<\/span><\/span><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a1edabfcd850\" id=\"forminator-field-text-3_6a1edabfcd850-label\" class=\"forminator-label\">Special Assessments Or Therapies Required:<\/label><span id=\"forminator-field-text-3_6a1edabfcd850-description\" class=\"forminator-description\"><span data-limit=\"8000\" data-type=\"words\">0 \/ 8000<\/span><\/span><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a1edabfcd850\" id=\"forminator-field-text-4_6a1edabfcd850-label\" class=\"forminator-label\">Notes For Practitioners (Additional Relevant Details):<\/label><span id=\"forminator-field-text-4_6a1edabfcd850-description\" class=\"forminator-description\"><span data-limit=\"8000\" data-type=\"words\">0 \/ 8000<\/span><\/span><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a1edabfcd850\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-5\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Booking Details<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a1edabfcd850-label\"><span id=\"forminator-radiogroup-radio-2-6a1edabfcd850-label\" class=\"forminator-label\">Preferred Consultation Type(s): <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a1edabfcd850\" class=\"forminator-radio\" title=\"In Clinic\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a1edabfcd850\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">In Clinic<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a1edabfcd850\" class=\"forminator-radio\" title=\"In Home Service\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a1edabfcd850\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">In Home Service<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-6a1edabfcd850\" class=\"forminator-radio\" title=\"Telehealth\"><input type=\"radio\" name=\"radio-2\" value=\"Telehealth\" id=\"forminator-field-radio-2-3-6a1edabfcd850\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Telehealth<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-6a1edabfcd850\" class=\"forminator-radio\" title=\"Community\"><input type=\"radio\" name=\"radio-2\" value=\"Community\" id=\"forminator-field-radio-2-4-6a1edabfcd850\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Community<\/span><\/label><\/div><\/div><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-8_6a1edabfcd850\" id=\"forminator-form-2704__field--select-8_6a1edabfcd850-label\" class=\"forminator-label\">Who Should We Contact To Make An Appointment? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-8_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-8\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-8_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">Participant\/Nominee<\/option><option value=\"two\"  data-calculation=\"0\">Support Coordinator<\/option><option value=\"custom_option\"  data-calculation=\"0\">Other<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-2704__field--select-8_6a1edabfcd850\" name=\"custom-select-8\" class=\"forminator-input\" aria-label=\"Other\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a1edabfcd850\" id=\"forminator-field-textarea-1_6a1edabfcd850-label\" class=\"forminator-label\">Notes For Reception Staff (If Applicable):<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a1edabfcd850\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-6\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">NDIS Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-9\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2704__field--select-9_6a1edabfcd850\" id=\"forminator-form-2704__field--select-9_6a1edabfcd850-label\" class=\"forminator-label\">Participant\u2019s NDIS Plan Type <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-2704__field--select-9_6a1edabfcd850\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-9\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please Select\" data-search=\"false\" data-search-placeholder=\"Please Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2704__field--select-9_6a1edabfcd850-label\"><option value=\"\"  >Please Select<\/option><option value=\"one\"  data-calculation=\"0\">NDIA Managed<\/option><option value=\"two\"  data-calculation=\"0\">Plan Managed<\/option><option value=\"Self-Nominee-Managed\"  data-calculation=\"0\">Self\/Nominee Managed<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"10814facac\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/2705\" \/><input type=\"hidden\" name=\"form_id\" value=\"2704\"><input type=\"hidden\" name=\"page_id\" value=\"2705\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/yoursolace.com\/index.php\/referral\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-2705","page","type-page","status-publish","hentry","entry","owp-thumbs-layout-horizontal","owp-btn-normal","owp-tabs-layout-horizontal","has-no-thumbnails","has-product-nav"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/pages\/2705","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/comments?post=2705"}],"version-history":[{"count":1,"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/pages\/2705\/revisions"}],"predecessor-version":[{"id":2706,"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/pages\/2705\/revisions\/2706"}],"wp:attachment":[{"href":"https:\/\/yoursolace.com\/index.php\/wp-json\/wp\/v2\/media?parent=2705"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}