{"id":5155,"date":"2024-05-20T23:14:56","date_gmt":"2024-05-21T06:14:56","guid":{"rendered":"https:\/\/glom-sap.org\/dev\/?page_id=5155"},"modified":"2024-05-20T23:18:40","modified_gmt":"2024-05-21T06:18:40","slug":"sap-callback-request-form","status":"publish","type":"page","link":"https:\/\/glom-sap.org\/dev\/sap-callback-request-form\/","title":{"rendered":"SAP Callback Request Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5155\" class=\"elementor elementor-5155\" 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_5' style='display:none'><div id='gf_5' 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_5'  action='\/dev\/wp-json\/wp\/v2\/pages\/5155#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' 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'>2<\/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_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_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_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_5_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 Callback Request Form<\/h3><\/div><fieldset id=\"field_5_227\" 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_5_227'>\n                            \n                            <span id='input_5_227_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_227_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_227.3' id='input_5_227_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_5_227_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_227_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_227.6' id='input_5_227_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_228\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_228'>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_228' id='input_5_228' type='text' value='' class='large' maxlength='2'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_229\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_229'>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_229' id='input_5_229' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_230\" class=\"gfield gfield--type-address gfield--input-type-address 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' >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_5_230' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_230_1_container' >\n                                        <label for='input_5_230_1' id='input_5_230_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_230.1' id='input_5_230_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_230_2_container' >\n                                        <label for='input_5_230_2' id='input_5_230_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_230.2' id='input_5_230_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_230_3_container' >\n                                    <label for='input_5_230_3' id='input_5_230_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_230.3' id='input_5_230_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_230_4_container' >\n                                        <label for='input_5_230_4' id='input_5_230_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_230.4' id='input_5_230_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_5_230_5_container' >\n                                    <label for='input_5_230_5' id='input_5_230_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_230.5' id='input_5_230_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_230.6' id='input_5_230_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_5_231\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >N\/A<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_231'><div class='gchoice gchoice_5_231_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_231.1' type='checkbox'  value='No address available'  id='choice_5_231_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_231_1' id='label_5_231_1' class='gform-field-label gform-field-label--type-inline'>No address available<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_232\" 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_5_232'>Phone Number<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_232' id='input_5_232' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_233\" 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' >Number Type<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_5_233'>\n\t\t\t<div class='gchoice gchoice_5_233_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Mobile'  id='choice_5_233_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_233_0' id='label_5_233_0' class='gform-field-label gform-field-label--type-inline'>Mobile<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_233_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Office'  id='choice_5_233_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_233_1' id='label_5_233_1' class='gform-field-label gform-field-label--type-inline'>Office<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_233_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Message Line'  id='choice_5_233_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_233_2' id='label_5_233_2' class='gform-field-label gform-field-label--type-inline'>Message Line<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_234\" 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' >Current Medical Insurance:<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_5_234'>\n\t\t\t<div class='gchoice gchoice_5_234_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='Yes'  id='choice_5_234_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_234_0' id='label_5_234_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_5_234_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='No'  id='choice_5_234_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_234_1' id='label_5_234_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_5_234_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='Unknown'  id='choice_5_234_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_234_2' id='label_5_234_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_235\" 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_5_235'>Please list type<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_235' id='input_5_235' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_237\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Best time to receive a call back<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_5_237'><div class='gchoice gchoice_5_237_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.1' type='checkbox'  value='Anytime between 8:00 AM \u2013 3:00 PM (PST)'  id='choice_5_237_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_1' id='label_5_237_1' class='gform-field-label gform-field-label--type-inline'>Anytime between 8:00 AM \u2013 3:00 PM (PST)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.2' type='checkbox'  value='8:00 AM \u2013 8:30 AM'  id='choice_5_237_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_2' id='label_5_237_2' class='gform-field-label gform-field-label--type-inline'>8:00 AM \u2013 8:30 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.3' type='checkbox'  value='8:30 AM \u2013 9:00 AM'  id='choice_5_237_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_3' id='label_5_237_3' class='gform-field-label gform-field-label--type-inline'>8:30 AM \u2013 9:00 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.4' type='checkbox'  value='9:00 AM- 9:30 AM'  id='choice_5_237_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_4' id='label_5_237_4' class='gform-field-label gform-field-label--type-inline'>9:00 AM- 9:30 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.5' type='checkbox'  value='9:30AM-10:00 AM'  id='choice_5_237_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_5' id='label_5_237_5' class='gform-field-label gform-field-label--type-inline'>9:30AM-10:00 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.6' type='checkbox'  value='10:00 AM \u201310:30 AM'  id='choice_5_237_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_6' id='label_5_237_6' class='gform-field-label gform-field-label--type-inline'>10:00 AM \u201310:30 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.7' type='checkbox'  value='10:30 AM\u201311:00 AM'  id='choice_5_237_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_7' id='label_5_237_7' class='gform-field-label gform-field-label--type-inline'>10:30 AM\u201311:00 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.8' type='checkbox'  value='11:00 AM-11:30 AM'  id='choice_5_237_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_8' id='label_5_237_8' class='gform-field-label gform-field-label--type-inline'>11:00 AM-11:30 AM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.9' type='checkbox'  value='11:30 AM-12:00 PM'  id='choice_5_237_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_9' id='label_5_237_9' class='gform-field-label gform-field-label--type-inline'>11:30 AM-12:00 PM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.11' type='checkbox'  value='12:00 PM \u2013 1:30 PM'  id='choice_5_237_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_11' id='label_5_237_11' class='gform-field-label gform-field-label--type-inline'>12:00 PM \u2013 1:30 PM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.12' type='checkbox'  value='1:30 PM-2:00 PM'  id='choice_5_237_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_12' id='label_5_237_12' class='gform-field-label gform-field-label--type-inline'>1:30 PM-2:00 PM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.13' type='checkbox'  value='2:00 PM-2:30 PM'  id='choice_5_237_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_13' id='label_5_237_13' class='gform-field-label gform-field-label--type-inline'>2:00 PM-2:30 PM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_237_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.14' type='checkbox'  value='2:30 PM \u2013 3:00 PM'  id='choice_5_237_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_237_14' id='label_5_237_14' class='gform-field-label gform-field-label--type-inline'>2:30 PM \u2013 3:00 PM<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_238\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Best day to receive a return call<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_5_238'><div class='gchoice gchoice_5_238_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.1' type='checkbox'  value='Any weekday'  id='choice_5_238_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_1' id='label_5_238_1' class='gform-field-label gform-field-label--type-inline'>Any weekday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_238_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.2' type='checkbox'  value='Monday'  id='choice_5_238_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_2' id='label_5_238_2' class='gform-field-label gform-field-label--type-inline'>Monday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_238_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.3' type='checkbox'  value='Tuesday'  id='choice_5_238_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_3' id='label_5_238_3' class='gform-field-label gform-field-label--type-inline'>Tuesday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_238_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.4' type='checkbox'  value='Wednesday'  id='choice_5_238_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_4' id='label_5_238_4' class='gform-field-label gform-field-label--type-inline'>Wednesday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_238_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.5' type='checkbox'  value='Thursday'  id='choice_5_238_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_5' id='label_5_238_5' class='gform-field-label gform-field-label--type-inline'>Thursday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_238_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.6' type='checkbox'  value='Friday'  id='choice_5_238_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_6' id='label_5_238_6' class='gform-field-label gform-field-label--type-inline'>Friday<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_238_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.7' type='checkbox'  value=''  id='choice_5_238_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_238_7' id='label_5_238_7' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_239\" 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' >Reason for Admission request<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_239'><div class='gchoice gchoice_5_239_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.1' type='checkbox'  value='New'  id='choice_5_239_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_239_1' id='label_5_239_1' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_239_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.2' type='checkbox'  value='Detox'  id='choice_5_239_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_239_2' id='label_5_239_2' class='gform-field-label gform-field-label--type-inline'>Detox<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_239_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.3' type='checkbox'  value='Readmission'  id='choice_5_239_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_239_3' id='label_5_239_3' class='gform-field-label gform-field-label--type-inline'>Readmission<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_240\" 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_5_240'>How did you hear about our SAP Program<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_240' id='input_5_240' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_241' 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_5_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_5_2' class='gform_page' data-js='page-field-id-241' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_5_243\" 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_5_243'>Digital File Upload<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_243' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_243&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_243&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_243&quot;,&quot;filelist&quot;:&quot;gform_preview_5_243&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;:5,&quot;field_id&quot;:243,&quot;_gform_file_upload_nonce_5_243&quot;:&quot;50d8456e8d&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_243&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_5_243' 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_5_243' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_243\"  >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_5_243'>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_5_243'><\/ul> <div id='gform_preview_5_243' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_242\" 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 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\">Face Sheet (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\">ROI<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_5' 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='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <button type='button'  id='gform_save_5_footer_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\" 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