{"id":25275,"date":"2024-04-17T19:05:27","date_gmt":"2024-04-17T19:05:27","guid":{"rendered":"https:\/\/diamondexperienceco.com\/?page_id=25275"},"modified":"2025-11-24T18:15:37","modified_gmt":"2025-11-24T18:15:37","slug":"referrals","status":"publish","type":"page","link":"https:\/\/diamondexperienceco.com\/es\/referrals\/","title":{"rendered":"Referencias"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"25275\" class=\"elementor elementor-25275\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b404e5b e-flex e-con-boxed e-con e-parent\" data-id=\"b404e5b\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-09e4ace elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"09e4ace\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Referrals<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-715c918 elementor-invisible elementor-widget elementor-widget-edublink-heading\" data-id=\"715c918\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;edublink--slide-up&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"edublink-heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"edublink-section-heading\"><div class=\"title-shape\"><i class=\"icon-19\"><\/i><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b5e8ce5 elementor-widget elementor-widget-text-editor\" data-id=\"b5e8ce5\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"color: #f26522;\"><a style=\"color: #f26522;\" href=\"https:\/\/diamondexperienceco.com\/\">HOME<\/a> \/\/ REFERRALS<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7c31aeb elementor-section-content-top elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7c31aeb\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;waves&quot;}\">\n\t\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M421.9,6.5c22.6-2.5,51.5,0.4,75.5,5.3c23.6,4.9,70.9,23.5,100.5,35.7c75.8,32.2,133.7,44.5,192.6,49.7\n\tc23.6,2.1,48.7,3.5,103.4-2.5c54.7-6,106.2-25.6,106.2-25.6V0H0v30.3c0,0,72,32.6,158.4,30.5c39.2-0.7,92.8-6.7,134-22.4\n\tc21.2-8.1,52.2-18.2,79.7-24.2C399.3,7.9,411.6,7.5,421.9,6.5z\"\/>\n<\/svg>\t\t<\/div>\n\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1c69d2a\" data-id=\"1c69d2a\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-efa1e3f elementor-invisible elementor-widget elementor-widget-edublink-heading\" data-id=\"efa1e3f\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"edublink-heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"edublink-section-heading\"><h3 class=\"heading\">Submit a Referral<\/h3><div class=\"title-shape\"><i class=\"icon-19\"><\/i><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8ae08ee elementor-widget elementor-widget-shortcode\" data-id=\"8ae08ee\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Referral<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/25275#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_30\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_30'>Facebook<\/label><div class='ginput_container'><input name='input_30' id='input_2_30' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_30'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_29'>Referral Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_29' id='input_2_29' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_29_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_29_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_29' class='gform_hidden' value='https:\/\/diamondexperienceco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Referral Source:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='large'    placeholder='Enter Name and Contact Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Referring Agency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_2_16' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Texas Department of Family and Protective Services' >Texas Department of Family and Protective Services<\/option><option value='Texas Department of Criminal Justice' >Texas Department of Criminal Justice<\/option><option value='School' >School<\/option><option value='Psychiatric Hospital' >Psychiatric Hospital<\/option><option value='Primary Care Physician' >Primary Care Physician<\/option><option value='Community Outreach' >Community Outreach<\/option><option value='Friend\/Family' >Friend\/Family<\/option><option value='Endeavors' >Endeavors<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Name of Agency<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>Name of School<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>Name of Friend\/Family<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Name of Hospital<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>Name of PCP\/Clinic<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Client Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Client Email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_10' id='input_2_10' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_13'>Client Date of Birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_2_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_13' class='gform_hidden' value='https:\/\/diamondexperienceco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Client Phone #:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_2_11' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_12\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_2_12_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_12_1' id='input_2_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_2_12_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_12_3' id='input_2_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_12_4_container' >\n                                        <select name='input_12.4' id='input_2_12_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_2_12_4' id='input_2_12_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_2_12_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_12_5' id='input_2_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_2_12_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Client Insurance Information:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='large'    placeholder='Enter Plan and ID Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is Parent\/Guardian Information Needed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_18'>\n\t\t\t<div class='gchoice gchoice_2_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_2_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_2_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Name of Parent\/ Guardian:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Parent\/ Guardian Email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>Parent\/ Guardian Phone #:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Current Mental Health Symptoms (Check All That Apply):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_14'><div class='gchoice gchoice_2_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Hallucinations'  id='choice_2_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>Hallucinations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Delusions'  id='choice_2_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_2' id='label_2_14_2' class='gform-field-label gform-field-label--type-inline'>Delusions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Thought Disorder'  id='choice_2_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_3' id='label_2_14_3' class='gform-field-label gform-field-label--type-inline'>Thought Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Psychotic Behavior'  id='choice_2_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_4' id='label_2_14_4' class='gform-field-label gform-field-label--type-inline'>Psychotic Behavior<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Anxiety\/Nervousness'  id='choice_2_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_5' id='label_2_14_5' class='gform-field-label gform-field-label--type-inline'>Anxiety\/Nervousness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Obsessive or Compulsive Behavior'  id='choice_2_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_6' id='label_2_14_6' class='gform-field-label gform-field-label--type-inline'>Obsessive or Compulsive Behavior<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='Phobias'  id='choice_2_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_7' id='label_2_14_7' class='gform-field-label gform-field-label--type-inline'>Phobias<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='Depression'  id='choice_2_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_8' id='label_2_14_8' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='Sleep Disturbances'  id='choice_2_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_9' id='label_2_14_9' class='gform-field-label gform-field-label--type-inline'>Sleep Disturbances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='Irritability'  id='choice_2_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_11' id='label_2_14_11' class='gform-field-label gform-field-label--type-inline'>Irritability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.12' type='checkbox'  value='Hyperactivity'  id='choice_2_14_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_12' id='label_2_14_12' class='gform-field-label gform-field-label--type-inline'>Hyperactivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.13' type='checkbox'  value='Attention-Deficit'  id='choice_2_14_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_13' id='label_2_14_13' class='gform-field-label gform-field-label--type-inline'>Attention-Deficit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.14' type='checkbox'  value='Anger\/Temper Tantrums'  id='choice_2_14_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_14' id='label_2_14_14' class='gform-field-label gform-field-label--type-inline'>Anger\/Temper Tantrums<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.15' type='checkbox'  value='Eating Problems'  id='choice_2_14_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_15' id='label_2_14_15' class='gform-field-label gform-field-label--type-inline'>Eating Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.16' type='checkbox'  value='Elimination Problems'  id='choice_2_14_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_16' id='label_2_14_16' class='gform-field-label gform-field-label--type-inline'>Elimination Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.17' type='checkbox'  value='Oppositional\/Defiant'  id='choice_2_14_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_17' id='label_2_14_17' class='gform-field-label gform-field-label--type-inline'>Oppositional\/Defiant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.18' type='checkbox'  value='Antisocial Behavior'  id='choice_2_14_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_18' id='label_2_14_18' class='gform-field-label gform-field-label--type-inline'>Antisocial Behavior<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.19' type='checkbox'  value='Delinquent\/Conduct Disorder'  id='choice_2_14_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_19' id='label_2_14_19' class='gform-field-label gform-field-label--type-inline'>Delinquent\/Conduct Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.21' type='checkbox'  value='Oversexual Behavior'  id='choice_2_14_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_21' id='label_2_14_21' class='gform-field-label gform-field-label--type-inline'>Oversexual Behavior<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.22' type='checkbox'  value='Attachment Issues'  id='choice_2_14_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_22' id='label_2_14_22' class='gform-field-label gform-field-label--type-inline'>Attachment Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.23' type='checkbox'  value='Somatic Complaints'  id='choice_2_14_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_23' id='label_2_14_23' class='gform-field-label gform-field-label--type-inline'>Somatic Complaints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_14_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.24' type='checkbox'  value='Other (Specify Below):'  id='choice_2_14_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_24' id='label_2_14_24' class='gform-field-label gform-field-label--type-inline'>Other (Specify Below):<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_15\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Please describe the specific behaviors of the client, and need for mental health services, as well as any other information deemed important for us to know:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_2_15' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=1&amp;description=1&amp;tabindex=0&amp;theme=orbital&amp;styles=[]&amp;hash=f07b07f48e0b12c96415c0119b14d8b3' \/>\n            <input type='hidden' 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