{"id":163,"date":"2026-05-02T15:31:22","date_gmt":"2026-05-02T05:31:22","guid":{"rendered":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/?page_id=163"},"modified":"2026-05-02T16:05:13","modified_gmt":"2026-05-02T06:05:13","slug":"referrals","status":"publish","type":"page","link":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/referrals\/","title":{"rendered":"Referrals"},"content":{"rendered":"<div class=\"inner-sec mb-5\">\n<div class=\"container\">\n<div class=\"row justify-content-center\">\n<div class=\"col-lg-7 col-md-10 col-sm-12\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f166-o1\" lang=\"en-AU\" dir=\"ltr\" data-wpcf7-id=\"166\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/devsite\/chosen-care\/wp-json\/wp\/v2\/pages\/163#wpcf7-f166-o1\" method=\"post\" class=\"wpcf7-form init cf7mls-no-scroll cf7mls-no-moving-animation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"166\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_AU\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f166-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:166,&quot;conditions&quot;:[],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;}}\" \/>\n<\/fieldset>\n<div class=\"ref_form_box mb-4\">\n\t<div class=\"inner-heading\">\n\t\t<p>Ready To Get Started?\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>I am completing this for\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"completing\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"completing\"><option value=\"\">Please Select<\/option><option value=\"Myself as the participant\">Myself as the participant<\/option><option value=\"Someone I am referring to Chosen Care\">Someone I am referring to Chosen Care<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box mb-4\">\n\t<div class=\"inner-heading\">\n\t\t<p>Participant Details\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>First Name\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-first-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Last Name\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-last-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Date of Birth\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Gender\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"gender\"><option value=\"\">Please Select<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Prefer not to say\">Prefer not to say<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Home Address\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant Phone Number\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant Email Address\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant NDIS Number\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ndis-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ndis-number\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Does The Participant Have A Legal Guardian \/ Nominee?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_radio\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"legal-guardian\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"legal-guardian\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"legal-guardian\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box mb-4\">\n\t<div class=\"inner-heading\">\n\t\t<p>Cultural Details\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant Country Of Birth\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"birth-country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"birth-country\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Does The Participant Require An Interpreter?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"interpreter\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"interpreter\"><option value=\"\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Relevant Culture Or Religious Considerations(If Any)?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"religious-considerations\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"religious-considerations\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Does The Listed Participant Identify As An Aboriginal Or Torres Strait Islander?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"torres-strait\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"torres-strait\"><option value=\"\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box mb-4\">\n\t<div class=\"inner-heading\">\n\t\t<p>Services Request\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Type Of Primary Service Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"primary-service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"primary-service\"><option value=\"\">Please Select<\/option><option value=\"Life stage - Transitions\">Life stage - Transitions<\/option><option value=\"Personal Activities\">Personal Activities<\/option><option value=\"Travel\/Transport assistance\">Travel\/Transport assistance<\/option><option value=\"Daily Tasks \/ Shared Living\">Daily Tasks \/ Shared Living<\/option><option value=\"Community Participation\">Community Participation<\/option><option value=\"Development- Life skills\">Development- Life skills<\/option><option value=\"Houshold Tasks\">Houshold Tasks<\/option><option value=\"Participate Community\">Participate Community<\/option><option value=\"Group \/ Centre Activities\">Group \/ Centre Activities<\/option><option value=\"Support Coordination\">Support Coordination<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Number Of Hours Requested For Service:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"service-hour\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"service-hour\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Type Of Secondary Service Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"secondary-service\"><option value=\"\">Please Select<\/option><option value=\"Life stage - Transitions\">Life stage - Transitions<\/option><option value=\"Personal Activities\">Personal Activities<\/option><option value=\"Travel\/Transport assistance\">Travel\/Transport assistance<\/option><option value=\"Daily Tasks \/ Shared Living\">Daily Tasks \/ Shared Living<\/option><option value=\"Community Participation\">Community Participation<\/option><option value=\"Development- Life skills\">Development- Life skills<\/option><option value=\"Houshold Tasks\">Houshold Tasks<\/option><option value=\"Participate Community\">Participate Community<\/option><option value=\"Group \/ Centre Activities\">Group \/ Centre Activities<\/option><option value=\"Support Coordination\">Support Coordination<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Additional Service Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"additional-service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"additional-service\"><option value=\"\">Please Select<\/option><option value=\"Life stage - Transitions\">Life stage - Transitions<\/option><option value=\"Personal Activities\">Personal Activities<\/option><option value=\"Travel\/Transport assistance\">Travel\/Transport assistance<\/option><option value=\"Daily Tasks \/ Shared Living\">Daily Tasks \/ Shared Living<\/option><option value=\"Community Participation\">Community Participation<\/option><option value=\"Development- Life skills\">Development- Life skills<\/option><option value=\"Houshold Tasks\">Houshold Tasks<\/option><option value=\"Participate Community\">Participate Community<\/option><option value=\"Group \/ Centre Activities\">Group \/ Centre Activities<\/option><option value=\"Support Coordination\">Support Coordination<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant's Relevant Conditions \/ Disability (Please List):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"relevant-conditions\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"relevant-conditions\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Extra Information That May Assist With Preparation For Initial Appointment:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"extra-information\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"extra-information\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Special Assessments Or Therapies Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"special-assessments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"special-assessments\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Notes For Practitioners (Additional Relevant Details):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"relevant-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"relevant-details\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box mb-4\">\n\t<div class=\"inner-heading\">\n\t\t<p>Booking Details\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Preferred Consultation Type(s):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_radio\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consultation-type\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"In Clinic\" \/><span class=\"wpcf7-list-item-label\">In Clinic<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"In Home Service\" \/><span class=\"wpcf7-list-item-label\">In Home Service<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"Telehealth\" \/><span class=\"wpcf7-list-item-label\">Telehealth<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"Community\" \/><span class=\"wpcf7-list-item-label\">Community<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Who Should We Contact To Make An Appointment?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact-appointment\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"contact-appointment\"><option value=\"\">Please Select<\/option><option value=\"Participant\/ Nominee\">Participant\/ Nominee<\/option><option value=\"Support Coordinator\">Support Coordinator<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-12 col-md-12 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Notes For Reception Staff (If Applicable):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reception-staff\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"reception-staff\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box\">\n\t<div class=\"inner-heading\">\n\t\t<p>NDIS Information\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-12 col-md-12 mb-3\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant\u2019s NDIS Plan Type\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ndis-plan-type\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"ndis-plan-type\"><option value=\"\">Please Select<\/option><option value=\"NDIA Managed\">NDIA Managed<\/option><option value=\"Plan Managed\">Plan Managed<\/option><option value=\"Self\/ Nominee-Managed\">Self\/ Nominee-Managed<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-12 col-md-12 contact-btn mt-3\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/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":"page-templates\/full-width.php","meta":{"footnotes":""},"class_list":["post-163","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/pages\/163","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/comments?post=163"}],"version-history":[{"count":4,"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/pages\/163\/revisions"}],"predecessor-version":[{"id":179,"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/pages\/163\/revisions\/179"}],"wp:attachment":[{"href":"https:\/\/jr-technologiesweb.com\/devsite\/chosen-care\/wp-json\/wp\/v2\/media?parent=163"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}