{"id":519,"date":"2023-01-24T11:42:36","date_gmt":"2023-01-24T11:42:36","guid":{"rendered":"https:\/\/calonadhdproject.org\/?page_id=519"},"modified":"2023-01-24T11:55:29","modified_gmt":"2023-01-24T11:55:29","slug":"referral","status":"publish","type":"page","link":"https:\/\/calonadhdproject.org\/?page_id=519","title":{"rendered":"REFERRAL Request Form"},"content":{"rendered":"\n<p>Please enter your referral details below and click Submit.<\/p>\n\n\n\n<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f516-o1\" lang=\"en-GB\" dir=\"ltr\" data-wpcf7-id=\"516\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F519#wpcf7-f516-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"516\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_GB\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f516-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><label> Referring Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-referrer-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=\"text-referrer-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email Adress:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-referrer\"><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=\"email-referrer\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-referrer\"><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=\"tel-referrer\" \/><\/span> <\/label>\n<\/p>\n<p><label>Patient Information:<\/label>\n<\/p>\n<p>Gender:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-patient-gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-patient-gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-patient-gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Interpreter required:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-patient-interpreter\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-patient-interpreter\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-patient-interpreter\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Guardian language:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-guardian-language\"><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=\"text-guardian-language\" \/><\/span> <\/label>\n<\/p>\n<p><label> Patient language:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-patient-language\"><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=\"text-patient-language\" \/><\/span> <\/label>\n<\/p>\n<p><label> Guardian Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-guardian-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=\"text-guardian-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Patient Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-patient-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=\"text-patient-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Patient Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-patient-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"text-patient-address\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Date of birth:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-birthdate\"><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=\"patient-birthdate\" \/><\/span><\/label>\n<\/p>\n<p><label> Email Adress:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-patient\"><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=\"email-patient\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-patient\"><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=\"tel-patient\" \/><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\n\n\n<p><\/p>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Please enter your referral details below and click Submit.<\/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":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center 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