{"id":5009,"date":"2024-02-18T21:52:35","date_gmt":"2024-02-19T05:52:35","guid":{"rendered":"https:\/\/glom-sap.org\/dev\/?page_id=5009"},"modified":"2024-09-10T13:17:44","modified_gmt":"2024-09-10T20:17:44","slug":"sap-intake-form","status":"publish","type":"page","link":"https:\/\/glom-sap.org\/dev\/sap-intake-form\/","title":{"rendered":"SAP Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5009\" class=\"elementor elementor-5009\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-ab11dd3 e-flex e-con-boxed e-con e-parent\" data-id=\"ab11dd3\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-359477b elementor-widget elementor-widget-image\" data-id=\"359477b\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"800\" height=\"250\" src=\"https:\/\/glom-sap.org\/dev\/wp-content\/uploads\/cropped-G.L.O.M.-Substance-Abuse-Program-Inc.-Full-Color-Logo-1-1024x320.png\" class=\"attachment-large size-large wp-image-3788\" alt=\"\" srcset=\"https:\/\/glom-sap.org\/dev\/wp-content\/uploads\/cropped-G.L.O.M.-Substance-Abuse-Program-Inc.-Full-Color-Logo-1-1024x320.png 1024w, https:\/\/glom-sap.org\/dev\/wp-content\/uploads\/cropped-G.L.O.M.-Substance-Abuse-Program-Inc.-Full-Color-Logo-1-300x94.png 300w, https:\/\/glom-sap.org\/dev\/wp-content\/uploads\/cropped-G.L.O.M.-Substance-Abuse-Program-Inc.-Full-Color-Logo-1-768x240.png 768w, https:\/\/glom-sap.org\/dev\/wp-content\/uploads\/cropped-G.L.O.M.-Substance-Abuse-Program-Inc.-Full-Color-Logo-1.png 1213w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/>\t\t\t\t\t\t\t\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<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-6912e39 e-flex e-con-boxed e-con e-parent\" data-id=\"6912e39\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a7a5182 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"a7a5182\" data-element_type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form eael-contact-form-align-default\">\n\t\t        <script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/dev\/wp-json\/wp\/v2\/pages\/5009#gf_4' data-formid='4' novalidate>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_4_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SAP REFERRAL CHECKLIST<\/h3><\/div><fieldset id=\"field_4_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Completed Referral Forms<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_72'>\n\t\t\t<div class='gchoice gchoice_4_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_4_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_72_0' id='label_4_72_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_4_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_4_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Client signed (ROI)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_74'>\n\t\t\t<div class='gchoice gchoice_4_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_4_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_74_0' id='label_4_74_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_4_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_4_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_175\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Presumed detox\/MAT<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_175'>\n\t\t\t<div class='gchoice gchoice_4_175_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_175' type='radio' value='Yes'  id='choice_4_175_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_175_0' id='label_4_175_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_4_175_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_175' type='radio' value='No'  id='choice_4_175_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_175_1' id='label_4_175_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_175_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_175' type='radio' value='N\/A'  id='choice_4_175_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_175_2' id='label_4_175_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2-sets of vitals (at least 1hr gap)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_75'>\n\t\t\t<div class='gchoice gchoice_4_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_4_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_0' id='label_4_75_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_4_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_4_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_1' id='label_4_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_75_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='N\/A'  id='choice_4_75_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_2' id='label_4_75_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_33\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-two-thirds field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date\/Time<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Set 1 - Date<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Set 1 - Time<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Set 2 - Date<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Set 2 - Time<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_33_cell1 gform-grid-col' data-label='Set 1 - Date'><input aria-invalid='false'   aria-label='Set 1 - Date, Row 1' data-aria-label-template='Set 1 - Date, Row {0}' type='text' name='input_33[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_33_cell2 gform-grid-col' data-label='Set 1 - Time'><input aria-invalid='false'   aria-label='Set 1 - Time, Row 1' data-aria-label-template='Set 1 - Time, Row {0}' type='text' name='input_33[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_33_cell3 gform-grid-col' data-label='Set 2 - Date'><input aria-invalid='false'   aria-label='Set 2 - Date, Row 1' data-aria-label-template='Set 2 - Date, Row {0}' type='text' name='input_33[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_33_cell4 gform-grid-col' data-label='Set 2 - Time'><input aria-invalid='false'   aria-label='Set 2 - Time, Row 1' data-aria-label-template='Set 2 - Time, Row {0}' type='text' name='input_33[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have CIWA and COWS been completed<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_76'>\n\t\t\t<div class='gchoice gchoice_4_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_4_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_0' id='label_4_76_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_4_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_4_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_1' id='label_4_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='N\/A'  id='choice_4_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_2' id='label_4_76_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Proof of negative TB\/PPD results attached<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_77'>\n\t\t\t<div class='gchoice gchoice_4_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_4_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_77_0' id='label_4_77_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_4_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_4_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_77_1' id='label_4_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_176\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Physician Report\/Physical<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_176'>\n\t\t\t<div class='gchoice gchoice_4_176_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_176' type='radio' value='Yes'  id='choice_4_176_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_176_0' id='label_4_176_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_4_176_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_176' type='radio' value='No'  id='choice_4_176_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_176_1' id='label_4_176_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Proof of Insurance\/Payment Arrangement Plan<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_4_79'>\n\t\t\t<div class='gchoice gchoice_4_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_4_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_79_0' id='label_4_79_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_4_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_4_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_79_1' id='label_4_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_79_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='N\/A'  id='choice_4_79_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_79_2' id='label_4_79_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_234\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_234'>Type of Insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_234' id='input_4_234' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Med Order\/PRN Order from Healthcare Provider<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_4_78'>\n\t\t\t<div class='gchoice gchoice_4_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_4_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_0' id='label_4_78_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_4_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_4_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_1' id='label_4_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='N\/A'  id='choice_4_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_2' id='label_4_78_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >CPAP Machine required<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_4_80'>\n\t\t\t<div class='gchoice gchoice_4_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_4_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_80_0' id='label_4_80_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_4_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_4_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_80_1' id='label_4_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='N\/A'  id='choice_4_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_80_2' id='label_4_80_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_177\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Epi-Pen required<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_4_177'>\n\t\t\t<div class='gchoice gchoice_4_177_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='Yes'  id='choice_4_177_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_177_0' id='label_4_177_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_4_177_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='No'  id='choice_4_177_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_177_1' id='label_4_177_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_177_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='N\/A'  id='choice_4_177_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_177_2' id='label_4_177_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_178\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Continuous Glucose Monitor required<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_4_178'>\n\t\t\t<div class='gchoice gchoice_4_178_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_178' type='radio' value='Yes'  id='choice_4_178_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_178_0' id='label_4_178_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_4_178_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_178' type='radio' value='No'  id='choice_4_178_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_178_1' id='label_4_178_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_178_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_178' type='radio' value='N\/A'  id='choice_4_178_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_178_2' id='label_4_178_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_47' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_4_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-47' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_4_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PARTICIPANT  INFORMATION<\/h3><\/div><fieldset id=\"field_4_49\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_49'>\n                            \n                            <span id='input_4_49_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_4_49_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_49.3' id='input_4_49_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_4_49_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_4_49_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_49.6' id='input_4_49_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_50'>Participant ID#<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_50' id='input_4_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_180\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_180'>Participant Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_180' id='input_4_180' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_230\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_230'>Secondary Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_230' id='input_4_230' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_51\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_51'>DOB<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_51' id='input_4_51' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_51_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_51_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_51' class='gform_hidden' value='https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_52'>Age<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_52' id='input_4_52' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Gender<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_54' id='input_4_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'>SS#<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_53' id='input_4_53' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_55'>Race<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_55' id='input_4_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_181\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_181'>Level of Education Completed<\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_4_181' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_182\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-three-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_182'>Religious Affiliation<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_4_182' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Applicable<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_183'>\n\t\t\t<div class='gchoice gchoice_4_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='N\/A'  id='choice_4_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_183_0' id='label_4_183_0' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_184\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_184'>Next of Kin<\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_4_184' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_186\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_186'>Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_186' id='input_4_186' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Applicable<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_187'>\n\t\t\t<div class='gchoice gchoice_4_187_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='N\/A'  id='choice_4_187_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_187_0' id='label_4_187_0' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_189\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_189'>Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_4_189' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_190\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_190'>Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_190' id='input_4_190' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_191\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Applicable<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_191'>\n\t\t\t<div class='gchoice gchoice_4_191_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_191' type='radio' value='N\/A'  id='choice_4_191_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_191_0' id='label_4_191_0' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_86\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_86'>Date of Arrival to Program<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_86' id='input_4_86' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_86_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_86_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_86' class='gform_hidden' value='https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_87\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>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_87' id='input_4_87' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_87_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_87_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_87' class='gform_hidden' value='https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_85'>Referring 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_85' id='input_4_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type of Admission<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_4_192'>\n\t\t\t<div class='gchoice gchoice_4_192_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='New'  id='choice_4_192_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_192_0' id='label_4_192_0' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_192_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Detox'  id='choice_4_192_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_192_1' id='label_4_192_1' class='gform-field-label gform-field-label--type-inline'>Detox<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_192_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Readmission'  id='choice_4_192_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_192_2' id='label_4_192_2' class='gform-field-label gform-field-label--type-inline'>Readmission<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_192_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Other'  id='choice_4_192_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_192_3' id='label_4_192_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_193\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_193'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_4_193' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_194\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><b>Provide information of last place of residency: <\/b><\/div><div id=\"field_4_91\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_91'>Facility\/Program Name<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_4_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_195\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_195'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_195' id='input_4_195' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_92\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-three-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Facility Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_92' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_92_1_container' >\n                                        <label for='input_4_92_1' id='input_4_92_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_92.1' id='input_4_92_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_4_92_2_container' >\n                                        <label for='input_4_92_2' id='input_4_92_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_92.2' id='input_4_92_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_92_3_container' >\n                                    <label for='input_4_92_3' id='input_4_92_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_92.3' id='input_4_92_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_92_4_container' >\n                                        <label for='input_4_92_4' id='input_4_92_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_92.4' id='input_4_92_4'     aria-required='false'    ><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                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_92_5_container' >\n                                    <label for='input_4_92_5' id='input_4_92_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_92.5' id='input_4_92_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_92.6' id='input_4_92_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_4_196\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Or<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_196'><div class='gchoice gchoice_4_196_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_196.1' type='checkbox'  value='Unknown'  id='choice_4_196_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_196_1' id='label_4_196_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_196_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_196.2' type='checkbox'  value='Homeless'  id='choice_4_196_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_196_2' id='label_4_196_2' class='gform-field-label gform-field-label--type-inline'>Homeless<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_95\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Legal Status<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_4_95'><div class='gchoice gchoice_4_95_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.1' type='checkbox'  value='PC 290'  id='choice_4_95_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_1' id='label_4_95_1' class='gform-field-label gform-field-label--type-inline'>PC 290<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.2' type='checkbox'  value='AB109'  id='choice_4_95_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_2' id='label_4_95_2' class='gform-field-label gform-field-label--type-inline'>AB109<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.3' type='checkbox'  value='Informal Probation'  id='choice_4_95_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_3' id='label_4_95_3' class='gform-field-label gform-field-label--type-inline'>Informal Probation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.4' type='checkbox'  value='Formal Probation'  id='choice_4_95_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_4' id='label_4_95_4' class='gform-field-label gform-field-label--type-inline'>Formal Probation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.5' type='checkbox'  value='CPS'  id='choice_4_95_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_5' id='label_4_95_5' class='gform-field-label gform-field-label--type-inline'>CPS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.6' type='checkbox'  value='Court'  id='choice_4_95_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_6' id='label_4_95_6' class='gform-field-label gform-field-label--type-inline'>Court<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.7' type='checkbox'  value='Parole'  id='choice_4_95_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_7' id='label_4_95_7' class='gform-field-label gform-field-label--type-inline'>Parole<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.8' type='checkbox'  value='Unknown'  id='choice_4_95_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_8' id='label_4_95_8' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_95_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.9' type='checkbox'  value='N\/A'  id='choice_4_95_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_95_9' id='label_4_95_9' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_96'>Parole\/Probation Officer<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_4_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_97'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_4_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_232\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_232'>Through which County?<\/label><div class='ginput_container ginput_container_text'><input name='input_232' id='input_4_232' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Employed<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_99'>\n\t\t\t<div class='gchoice gchoice_4_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Yes'  id='choice_4_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_99_0' id='label_4_99_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_4_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_4_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_99_1' id='label_4_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_199\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_199'>Last place of Employment<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_4_199' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_198\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_198'>Date Last Employed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_198' id='input_4_198' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_198_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_198_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_198' class='gform_hidden' value='https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_200\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_200'>Income Type<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_4_200' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_201\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_201'>Amount<\/label><div class='gfield_description' id='gfield_description_4_201'>\/per month<\/div><div class='ginput_container ginput_container_text'><input name='input_201' id='input_4_201' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_201\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_115\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_115'>If other, please list (include county):<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_4_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_202\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Staff Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_202'>\n                            \n                            <span id='input_4_202_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_4_202_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_202.3' id='input_4_202_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_4_202_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_4_202_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_202.6' id='input_4_202_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_203\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-two-thirds gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_203'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_4_203_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_4_203_valid' id='input_4_203_valid' \/><canvas id='input_4_203' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_4_203_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_4_203_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_4_203_data' name='input_4_203_data' value=''><\/div><\/div><div id=\"field_4_204\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_204'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_204' id='input_4_204' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_204_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_204_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_204' class='gform_hidden' value='https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_121' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_121' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_4_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_3' class='gform_page' data-js='page-field-id-121' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_4_122\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CLINICAL INFORMATION<\/h3><\/div><fieldset id=\"field_4_205\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Substance Use History<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_205'>\n\t\t\t<div class='gchoice gchoice_4_205_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='Yes'  id='choice_4_205_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_205_0' id='label_4_205_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_4_205_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='No'  id='choice_4_205_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_205_1' id='label_4_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_205_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='Unknown'  id='choice_4_205_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_205_2' id='label_4_205_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_206\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Pre-Diagnosed Mental Health Conditiona<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_206'>\n\t\t\t<div class='gchoice gchoice_4_206_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='Yes'  id='choice_4_206_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_206_0' id='label_4_206_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_4_206_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='No'  id='choice_4_206_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_206_1' id='label_4_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_206_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='Unknown'  id='choice_4_206_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_206_2' id='label_4_206_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_124'>Primary Diagnosis<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_4_124' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Applicable?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_125'>\n\t\t\t<div class='gchoice gchoice_4_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='N\/A'  id='choice_4_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_125_0' id='label_4_125_0' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_207\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_207'>Secondary Diagnosis<\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_4_207' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Applicable?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_208'>\n\t\t\t<div class='gchoice gchoice_4_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='N\/A'  id='choice_4_208_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_208_0' id='label_4_208_0' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Substance Use History<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_4_136'>\n\t\t\t<div class='gchoice gchoice_4_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_4_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_136_0' id='label_4_136_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_4_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_4_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_136_1' id='label_4_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_136_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Unknown'  id='choice_4_136_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_136_2' id='label_4_136_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_137'>If yes, explain<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_4_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_212' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_212' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_4_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_4' class='gform_page' data-js='page-field-id-212' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_4_149\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">MEDICAL INFORMATION<\/h3><\/div><div id=\"field_4_215\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_215'>Current physical medical conditions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_215' id='input_4_215' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Any open wounds\/Known infections<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_4_156'>Treatment is required prior to the participant is admitted\/<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_156'>\n\t\t\t<div class='gchoice gchoice_4_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_4_156_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_4_156\"   \/>\n\t\t\t\t\t<label for='choice_4_156_0' id='label_4_156_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_4_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_4_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_156_1' id='label_4_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_157\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_157'>If yes, list<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_157' id='input_4_157' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_216\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Any signs of incontinence\/ need of incontinence products (adult diapers)<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_4_216'>\n\t\t\t<div class='gchoice gchoice_4_216_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_216' type='radio' value='Yes'  id='choice_4_216_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_216_0' id='label_4_216_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_4_216_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_216' type='radio' value='No'  id='choice_4_216_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_216_1' id='label_4_216_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_217\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_217'>If yes, list<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_217' id='input_4_217' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_158\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-three-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_158'>Drugs of choice<\/label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_4_158' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Applicable?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_159'>\n\t\t\t<div class='gchoice gchoice_4_159_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='N\/A'  id='choice_4_159_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_159_0' id='label_4_159_0' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_160\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_160'><div class='gchoice gchoice_4_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Smoke'  id='choice_4_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_160_1' id='label_4_160_1' class='gform-field-label gform-field-label--type-inline'>Smoke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='Snort'  id='choice_4_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_160_2' id='label_4_160_2' class='gform-field-label gform-field-label--type-inline'>Snort<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_160_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.3' type='checkbox'  value='Inject'  id='choice_4_160_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_160_3' id='label_4_160_3' class='gform-field-label gform-field-label--type-inline'>Inject<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_160_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.4' type='checkbox'  value='Other'  id='choice_4_160_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_160_4' id='label_4_160_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_161\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_161'>If other, please list<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_161' id='input_4_161' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_163\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_163'>Date last used<\/label><div class='gfield_description' id='gfield_description_4_163'>Date of substance\/alcohol used last.<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_163' id='input_4_163' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_163_date_format gfield_description_4_163\" aria-invalid=\"false\" \/>\n                            <span id='input_4_163_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_163' class='gform_hidden' value='https:\/\/glom-sap.org\/dev\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Unknown<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_164'>\n\t\t\t<div class='gchoice gchoice_4_164_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='Unknown'  id='choice_4_164_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_164_0' id='label_4_164_0' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_220\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_220'>Length of use<\/label><div class='ginput_container ginput_container_text'><input name='input_220' id='input_4_220' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_219\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Unknown<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_219'>\n\t\t\t<div class='gchoice gchoice_4_219_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='Unknown'  id='choice_4_219_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_219_0' id='label_4_219_0' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_167\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Alcohol used in last 72 hours<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_4_167'>\n\t\t\t<div class='gchoice gchoice_4_167_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Yes'  id='choice_4_167_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_167_0' id='label_4_167_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_4_167_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='No'  id='choice_4_167_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_167_1' id='label_4_167_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_167_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Unknown'  id='choice_4_167_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_167_2' id='label_4_167_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_168\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If yes, does client have a history of blackout seizures<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_168'>\n\t\t\t<div class='gchoice gchoice_4_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes'  id='choice_4_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_168_0' id='label_4_168_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_4_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='No'  id='choice_4_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_168_1' id='label_4_168_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_168_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Unknown'  id='choice_4_168_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_168_2' id='label_4_168_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_169\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Benzodiazepine used in last 72 hours<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_4_169'>\n\t\t\t<div class='gchoice gchoice_4_169_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_169' type='radio' value='Yes'  id='choice_4_169_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_169_0' id='label_4_169_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_4_169_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_169' type='radio' value='No'  id='choice_4_169_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_169_1' id='label_4_169_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_169_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_169' type='radio' value='N\/A'  id='choice_4_169_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_169_2' id='label_4_169_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_170\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If yes, does client have a history of blackout seizures<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_170'>\n\t\t\t<div class='gchoice gchoice_4_170_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='Yes'  id='choice_4_170_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_170_0' id='label_4_170_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_4_170_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='No'  id='choice_4_170_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_170_1' id='label_4_170_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_170_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='Unknown'  id='choice_4_170_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_170_2' id='label_4_170_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_233\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Any opioid or narcotics used<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_4_233'>\n\t\t\t<div class='gchoice gchoice_4_233_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Yes'  id='choice_4_233_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_233_0' id='label_4_233_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_4_233_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='No'  id='choice_4_233_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_233_1' id='label_4_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_233_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='N\/A'  id='choice_4_233_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_233_2' id='label_4_233_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_226' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_226' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_4_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_5' class='gform_page' data-js='page-field-id-226' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_4_222\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Information<\/h3><div class='gsection_description' id='gfield_description_4_222'>Our Intake Team may need to contact you \n regarding this referral. Please include your information below.<\/div><\/div><fieldset id=\"field_4_223\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_223'>\n                            \n                            <span id='input_4_223_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_4_223_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_223.3' id='input_4_223_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_4_223_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_4_223_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_223.6' id='input_4_223_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_224\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_224'>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_224' id='input_4_224' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_225\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_225'>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_225' id='input_4_225' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_171\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Referral submissions missing and\/or documents will delay the intake process\n*** Pick-up Times TBD***\n<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_227' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_4_227' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_4_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_6' class='gform_page' data-js='page-field-id-227' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_6' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_4_229\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_4_229'>Digital File Upload<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_4_229' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_4_229&quot;,&quot;container&quot;:&quot;gform_multifile_upload_4_229&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_4_229&quot;,&quot;filelist&quot;:&quot;gform_preview_4_229&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/glom-sap.org\\\/dev\\\/?gf_page=170a5f4a694dd53&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/glom-sap.org\\\/dev\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/glom-sap.org\\\/dev\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;20971520b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:4,&quot;field_id&quot;:229,&quot;_gform_file_upload_nonce_4_229&quot;:&quot;b35f1c2224&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_4_229&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_4_229' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_4_229' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_4_229\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_229'>Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 20 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_4_229'><\/ul> <div id='gform_preview_4_229' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_4_228\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\t\t<div data-elementor-type=\"section\" data-elementor-id=\"5226\" class=\"elementor elementor-5226\" data-elementor-post-type=\"elementor_library\">\n\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-221afc09 e-flex e-con-boxed e-con e-parent\" data-id=\"221afc09\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-568423b1 elementor-widget elementor-widget-text-editor\" data-id=\"568423b1\" 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>Here is the list of documents requested for upload.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-524d84e9 elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"524d84e9\" data-element_type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Transitional Housing Referral Form<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Medical Checklist or Physician\u2019s Report (within 1 year)<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">List of all Current Medications (medical and psychiatric) \u2013 attach MARS<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">TB Skin Test or Chest X-Ray Clearance (must be within 1-year, same day testing applicable)<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Medi-Cal Printout (if applicable) 6. \u2610 Recent MD Progress notes (if applicable<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Recent CM Progress Notes (if applicable)<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">If coming from a medical or psychiatric hospital, discharge summary<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Most Recent Assessment (if applicable)<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 7c-4.5-4.5-10.6-7-17-7H256v128h128v-6.1c0-6.3-2.5-12.4-7-16.9z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Recent Crisis Screening (if applicable)<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-upload\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224 136V0H24C10.7 0 0 10.7 0 24v464c0 13.3 10.7 24 24 24h336c13.3 0 24-10.7 24-24V160H248c-13.2 0-24-10.8-24-24zm65.18 216.01H224v80c0 8.84-7.16 16-16 16h-32c-8.84 0-16-7.16-16-16v-80H94.82c-14.28 0-21.41-17.29-11.27-27.36l96.42-95.7c6.65-6.61 17.39-6.61 24.04 0l96.42 95.7c10.15 10.07 3.03 27.36-11.25 27.36zM377 105L279.1 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