{"id":6062,"date":"2025-11-28T17:21:19","date_gmt":"2025-11-28T17:21:19","guid":{"rendered":"https:\/\/safeharbor.agencypartnerinteractive.com\/?page_id=6062"},"modified":"2025-11-28T17:37:26","modified_gmt":"2025-11-28T17:37:26","slug":"test-form","status":"publish","type":"page","link":"https:\/\/safeharbor.agencypartnerinteractive.com\/?page_id=6062","title":{"rendered":"test form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css=&#8221;.vc_custom_1764351427726{padding-top: 200px !important;padding-bottom: 200px !important;}&#8221; woodmart_css_id=&#8221;6929ddbb9c3bf&#8221; responsive_spacing=&#8221;eyJwYXJhbV90eXBlIjoid29vZG1hcnRfcmVzcG9uc2l2ZV9zcGFjaW5nIiwic2VsZWN0b3JfaWQiOiI2OTI5ZGRiYjljM2JmIiwic2hvcnRjb2RlIjoidmNfcm93IiwiZGF0YSI6eyJ0YWJsZXQiOnt9LCJtb2JpbGUiOnt9fX0=&#8221; mobile_bg_img_hidden=&#8221;no&#8221; tablet_bg_img_hidden=&#8221;no&#8221; woodmart_parallax=&#8221;0&#8243; woodmart_gradient_switch=&#8221;no&#8221; woodmart_box_shadow=&#8221;no&#8221; wd_z_index=&#8221;no&#8221; woodmart_disable_overflow=&#8221;0&#8243; row_reverse_mobile=&#8221;0&#8243; row_reverse_tablet=&#8221;0&#8243;][vc_column]<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 gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_6' style='display:none'><style>#gform_wrapper_6[data-form-index=\"0\"].gform-theme,[data-parent-form=\"6_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F6062#gf_6' data-formid='6' novalidate><div id='gf_page_steps_6' class='gf_page_steps'><div id='gf_step_6_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Personal Information<\/span><\/div><div id='gf_step_6_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Responsible Party Information<\/span><\/div><div id='gf_step_6_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Insurance Information<\/span><\/div><div id='gf_step_6_4' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Visit Reason<\/span><\/div><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_page_6_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_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_86\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_86' id='input_6_86' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_6_89\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_89' id='input_6_89' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_6_92\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_92' id='input_6_92' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_6_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_6_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_6_10\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Personal Information<\/h2>\n\n<strong>Patient Contact Information<\/strong>\n<p>Please complete the following section with your legal information as it appears on your insurance card (if applicable):<\/p><\/div><div id=\"field_6_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_11'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='large'    placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='large'    placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full dob-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_6_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_13' class='gform_hidden' value='https:\/\/safeharbor.agencypartnerinteractive.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_14\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_14'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_6_14' type='tel' value='' class='large'  placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_15'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_6_15' type='email' value='' class='large'   placeholder='Email Address' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_6_17\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_17' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_17_1_container' >\n                                        <label for='input_6_17_1' id='input_6_17_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_17.1' id='input_6_17_1' value=''   placeholder='ABC Street' aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_17_3_container' >\n                                    <label for='input_6_17_3' id='input_6_17_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_17.3' id='input_6_17_3' value=''   placeholder='Texas' aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_17_4_container' >\n                                        <label for='input_6_17_4' id='input_6_17_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_17.4' id='input_6_17_4' value=''     placeholder='TX' aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_17_5_container' >\n                                    <label for='input_6_17_5' id='input_6_17_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_17.5' id='input_6_17_5' value=''   placeholder='01234' aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_17.6' id='input_6_17_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_18\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Patient Personal Information<\/strong><\/div><fieldset id=\"field_6_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender Assigned at Birth (sex)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_19'>\n\t\t\t<div class='gchoice gchoice_6_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Male'  id='choice_6_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_0' id='label_6_19_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Female'  id='choice_6_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_1' id='label_6_19_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>Gender Identity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_6_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='558' >Male<\/option><option value='559' >Female<\/option><option value='560' >Transgender Male \/ Trans Man \/ Female-to-Male<\/option><option value='561' >Transgender Female \/ Trans Woman \/ Male-to-Female<\/option><option value='562' >Genderqueer, neither exclusively male nor female<\/option><option value='563' >Decline to answer<\/option><\/select><\/div><\/div><div id=\"field_6_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_22'>Sexual Orientation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_6_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='565' >Straight \/ Heterosexual<\/option><option value='566' >Lesbian \/ Gay<\/option><option value='567' >Bisexual<\/option><option value='568' >Don&#039;t know<\/option><option value='569' >Decline to answer<\/option><\/select><\/div><\/div><div id=\"field_6_23\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_23'>Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_6_23' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='1' >Single<\/option><option value='2' >Married<\/option><option value='3' >Divorced<\/option><option value='4' >Legally Separated<\/option><option value='5' >Widowed<\/option><option value='6' >Unknown<\/option><\/select><\/div><\/div><div id=\"field_6_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Note: Please ensure all the details entered are accurate before submitting, as they cannot be changed afterward unless updated by your counselor or an administrator.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_3' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Continue'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-3' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_96\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_96' id='input_6_96' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_6_94\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_94'>Appointment date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_94' id='input_6_94' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_6_94_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_94_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_94' class='gform_hidden' value='https:\/\/safeharbor.agencypartnerinteractive.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_90\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_90'>Available slots<\/label><div class='ginput_container ginput_container_select'><select name='input_90' id='input_6_90' class='large gfield_select'     aria-invalid=\"false\" ><option value='First Choice' >First Choice<\/option><option value='Second Choice' >Second Choice<\/option><option value='Third Choice' >Third Choice<\/option><\/select><\/div><\/div><div id=\"field_6_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Responsible Party Information<\/strong><\/div><fieldset id=\"field_6_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you completing this form for someone else?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_25'>\n\t\t\t<div class='gchoice gchoice_6_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_6_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_25_0' id='label_6_25_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_6_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_6_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_25_1' id='label_6_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_73\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_73'>What is your relationship to the patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_73' id='input_6_73' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='01' >Spouse<\/option><option value='04' >Grandfather or grandmother<\/option><option value='05' >Grandson or granddaughter<\/option><option value='07' >Nephew or niece<\/option><option value='09' >Adopted child<\/option><option value='10' >Foster child<\/option><option value='15' >Ward<\/option><option value='17' >Stepson or stepdaughter<\/option><option value='19' >Child<\/option><option value='20' >Employee<\/option><option value='21' >Unknown<\/option><option value='22' >Handicapped dependent<\/option><option value='23' >Sponsored dependent<\/option><option value='24' >Dependent of a minor dependent<\/option><option value='29' >Significant other<\/option><option value='32' >Mother<\/option><option value='33' >Father<\/option><option value='34' >Other adult<\/option><option value='36' >Emancipated minor<\/option><option value='39' >Organ donor<\/option><option value='40' >Cadaver donor<\/option><option value='41' >Injured plaintiff<\/option><option value='43' >Child where insured has no financial responsibility<\/option><option value='53' >Life partner<\/option><option value='G8' >Other relationship<\/option><\/select><\/div><\/div><fieldset id=\"field_6_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you the responsible party for billing?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_74'>\n\t\t\t<div class='gchoice gchoice_6_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_6_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_74_0' id='label_6_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_6_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_6_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_74_1' id='label_6_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_28'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_6_28' type='text' value='' class='large'    placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_29'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_6_29' type='text' value='' class='large'    placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_31\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_31'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_6_31' type='tel' value='' class='large'  placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_32\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_32'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_32' id='input_6_32' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_6_33\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_33_1_container' >\n                                        <label for='input_6_33_1' id='input_6_33_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_33.1' id='input_6_33_1' value=''   placeholder='ABC street' aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_33_3_container' >\n                                    <label for='input_6_33_3' id='input_6_33_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_33.3' id='input_6_33_3' value=''   placeholder='Texas' aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_33_4_container' >\n                                        <label for='input_6_33_4' id='input_6_33_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_33.4' id='input_6_33_4' value=''     placeholder='TX' aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_33_5_container' >\n                                    <label for='input_6_33_5' id='input_6_33_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_33.5' id='input_6_33_5' value=''   placeholder='01234' aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_33.6' id='input_6_33_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_6_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender Assigned at Birth (sex)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_75'>\n\t\t\t<div class='gchoice gchoice_6_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Male'  id='choice_6_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_75_0' id='label_6_75_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Female'  id='choice_6_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_75_1' id='label_6_75_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_99\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Note: Please ensure all the details entered are accurate before submitting, as they cannot be changed afterward unless updated by your counselor or an administrator.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_27' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Back'  \/> <input type='button' id='gform_next_button_6_27' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Continue'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-27' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_36\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Insurance Information<\/h2>\n<\/div><div id=\"field_6_97\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_97'>Insurance Carrier<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_6_97' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select Insurance Carrier' >Select Insurance Carrier<\/option><option value='A &amp; I BENEFIT PLAN ADMINI' >A &amp; I BENEFIT PLAN ADMINI<\/option><option value='AARP HEALTH CARE OPTIONS' >AARP HEALTH CARE OPTIONS<\/option><option value='ADVANCED BENEFIT ADMINIST' >ADVANCED BENEFIT ADMINIST<\/option><option value='AETNA' >AETNA<\/option><option value='AETNA \/ U.S. HEALTHCARE' >AETNA \/ U.S. HEALTHCARE<\/option><option value='AETNA HEALTH CARE' >AETNA HEALTH CARE<\/option><option value='AETNA HEALTH INC.' >AETNA HEALTH INC.<\/option><option value='AETNA TX' >AETNA TX<\/option><option value='AFFORDABLE BENEFIT ADMINI' >AFFORDABLE BENEFIT ADMINI<\/option><option value='AIG CLAIM SERVICES, INC' >AIG CLAIM SERVICES, INC<\/option><option value='ALLIED INSURANCE CO' >ALLIED INSURANCE CO<\/option><option value='ALLSTATE INSURANCE CO' >ALLSTATE INSURANCE CO<\/option><option value='ALTIUS HEALTH PLANS' >ALTIUS HEALTH PLANS<\/option><option value='AMERICAN FAMILY INSURANCE' >AMERICAN FAMILY INSURANCE<\/option><option value='AMERICAN INSURANCE ADMINI' >AMERICAN INSURANCE ADMINI<\/option><option value='AMERICAN MEDICAL SECURITY' >AMERICAN MEDICAL SECURITY<\/option><option value='AMERICAN NATIONAL PROPERT' >AMERICAN NATIONAL PROPERT<\/option><option value='AMERICAN PROGRESSIVE' >AMERICAN PROGRESSIVE<\/option><option value='AMERICAN PUBLIC LIFE INSU' >AMERICAN PUBLIC LIFE INSU<\/option><option value='AMICA MUTUAL INSURANCE' >AMICA MUTUAL INSURANCE<\/option><option value='APIPA' >APIPA<\/option><option value='ARGONAUT INSURANCE COMPAN' >ARGONAUT INSURANCE COMPAN<\/option><option value='ASSOCIATED AMERICAN MUTUA' >ASSOCIATED AMERICAN MUTUA<\/option><option value='ATTORNEY&#039;S LIABILITY PROT' >ATTORNEY&#039;S LIABILITY PROT<\/option><option value='BANKERS LIFE AND CASUALTY' >BANKERS LIFE AND CASUALTY<\/option><option value='BCBS FEDERAL EMPLOYEES' >BCBS FEDERAL EMPLOYEES<\/option><option value='BCBS MA' >BCBS MA<\/option><option value='BEAR RIVER MUTUAL INSURAN' >BEAR RIVER MUTUAL INSURAN<\/option><option value='BENCHOICE INC' >BENCHOICE INC<\/option><option value='BENEFIT PLAN ADMINISTRATO' >BENEFIT PLAN ADMINISTRATO<\/option><option value='BERKSHIRE LIFE INSURANCE' >BERKSHIRE LIFE INSURANCE<\/option><option value='BITUMINOUS INSURANCE CO' >BITUMINOUS INSURANCE CO<\/option><option value='BLUE CROSS BLUE SHIELD OF' >BLUE CROSS BLUE SHIELD OF<\/option><option value='BROTHERHOOD MUTUAL INSURA' >BROTHERHOOD MUTUAL INSURA<\/option><option value='BURKLEY RISK SERVICES' >BURKLEY RISK SERVICES<\/option><option value='CALIFORNIA CASUALTY INSUR' >CALIFORNIA CASUALTY INSUR<\/option><option value='CARE FIRST BCBS' >CARE FIRST BCBS<\/option><option value='CDPHP' >CDPHP<\/option><option value='CENTRAL INSURANCE CO' >CENTRAL INSURANCE CO<\/option><option value='CHUBB GROUP OF INSURANCE' >CHUBB GROUP OF INSURANCE<\/option><option value='CIGNA HEALTH CARE' >CIGNA HEALTH CARE<\/option><option value='CIGNA HEALTHCARE OF UTAH,' >CIGNA HEALTHCARE OF UTAH,<\/option><option value='CIGNA STATE OF VERMONT' >CIGNA STATE OF VERMONT<\/option><option value='CITY MARKET FOOD &amp; PHARMA' >CITY MARKET FOOD &amp; PHARMA<\/option><option value='CIVIL SERVICE EMPLOYEES I' >CIVIL SERVICE EMPLOYEES I<\/option><\/select><\/div><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_38'>Member ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_6_38' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_40\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_40'>Group Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_40' id='input_6_40' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_41'>Effective Date of Coverage (EDOC)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_6_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_41' class='gform_hidden' value='https:\/\/safeharbor.agencypartnerinteractive.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_85\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_85'>Coverage Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_85' id='input_6_85' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='1' >Primary<\/option><option value='2' >Secondary<\/option><option value='3' >Tertiary<\/option><option value='4' >Workers<\/option><option value='5' >Auto<\/option><option value='6' >DME<\/option><\/select><\/div><\/div><div id=\"field_6_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_42'>Group Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_6_42' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_43\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_43'>Relationship to Patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_6_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='18' >Self<\/option><option value='01' >Spouse<\/option><option value='04' >Grandfather or Grandmother<\/option><option value='05' >Grandson or Granddaughter<\/option><option value='07' >Nephew or Niece<\/option><option value='09' >Adopted Child<\/option><option value='10' >Foster Child<\/option><option value='15' >Ward<\/option><option value='17' >Stepson or Stepdaughter<\/option><option value='19' >Child<\/option><option value='20' >Employee<\/option><option value='21' >Unknown<\/option><option value='22' >Handicapped Dependent<\/option><option value='23' >Sponsored Dependent<\/option><option value='24' >Dependent of a Minor Dependent<\/option><option value='29' >Significant Other<\/option><option value='32' >Mother<\/option><option value='33' >Father<\/option><option value='34' >Other Adult<\/option><option value='36' >Emancipated Minor<\/option><option value='39' >Organ Donor<\/option><option value='40' >Cadaver Donor<\/option><option value='41' >Injured Plaintiff<\/option><option value='43' >Child Where Insured Has No Financial Responsibility<\/option><option value='53' >Life Partner<\/option><option value='G8' >Other Relationship<\/option><\/select><\/div><\/div><div id=\"field_6_44\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_44'>Insurance Carrier Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_6_44' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_100\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Note: Please ensure all the details entered are accurate before submitting, as they cannot be changed afterward unless updated by your counselor or an administrator.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_57' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Back'  \/> <input type='button' id='gform_next_button_6_57' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Continue'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_4' class='gform_page' data-js='page-field-id-57' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_70\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Visit Reason<\/h2>\n\n<strong>May we let your provider know the reason for your visit?<\/strong><\/div><div id=\"field_6_102\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_102'>Visit Type<\/label><div class='ginput_container ginput_container_select'><select name='input_102' id='input_6_102' class='large gfield_select'     aria-invalid=\"false\" ><option value='In-Person' >In-Person<\/option><option value='Virtual' >Virtual<\/option><\/select><\/div><\/div><div id=\"field_6_71\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_71'>What are you going through?<\/label><div class='ginput_container ginput_container_select'><select name='input_71' id='input_6_71' class='large gfield_select'     aria-invalid=\"false\" ><option value='I\u2019m a new patient seeking therapy.' >I\u2019m a new patient seeking therapy.<\/option><option value='I\u2019m feeling anxious.' >I\u2019m feeling anxious.<\/option><option value='I\u2019m feeling depressed.' >I\u2019m feeling depressed.<\/option><option value='I need help in my relationship.' >I need help in my relationship.<\/option><option value='I need help with a divorce.' >I need help with a divorce.<\/option><option value='I\u2019ve experienced a traumatic event.' >I\u2019ve experienced a traumatic event.<\/option><option value='I need help in my parenting.' >I need help in my parenting.<\/option><option value='I\u2019m dealing with grief or loss.' >I\u2019m dealing with grief or loss.<\/option><option value='I\u2019m feeling lonely.' >I\u2019m feeling lonely.<\/option><option value='I\u2019m struggling with food.' >I\u2019m struggling with food.<\/option><option value='I\u2019m feeling angry often.' >I\u2019m feeling angry often.<\/option><option value='I need help with LGBTQIA+' >I need help with LGBTQIA+<\/option><option value='I\u2019m battling health problems.' >I\u2019m battling health problems.<\/option><option value='I\u2019m struggling with my identity.' >I\u2019m struggling with my identity.<\/option><option value='I\u2019m going through a lot of change right now.' >I\u2019m going through a lot of change right now.<\/option><option value='I\u2019m feeling burn out.' >I\u2019m feeling burn out.<\/option><option value='I need to talk about something else.' >I need to talk about something else.<\/option><\/select><\/div><\/div><fieldset id=\"field_6_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_72'>\n\t\t\t<div class='gchoice gchoice_6_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Friend or Family Member'  id='choice_6_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_0' id='label_6_72_0' class='gform-field-label gform-field-label--type-inline'>Friend or Family Member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='My Doctor'  id='choice_6_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_1' id='label_6_72_1' class='gform-field-label gform-field-label--type-inline'>My Doctor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='My Church'  id='choice_6_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_2' id='label_6_72_2' class='gform-field-label gform-field-label--type-inline'>My Church<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='My Insurance Provider'  id='choice_6_72_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_3' id='label_6_72_3' class='gform-field-label gform-field-label--type-inline'>My Insurance Provider<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='A Mental Health Provider'  id='choice_6_72_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_4' id='label_6_72_4' class='gform-field-label gform-field-label--type-inline'>A Mental Health Provider<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Google'  id='choice_6_72_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_5' id='label_6_72_5' class='gform-field-label gform-field-label--type-inline'>Google<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='AI Search (ChatGPT, etc)'  id='choice_6_72_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_6' id='label_6_72_6' class='gform-field-label gform-field-label--type-inline'>AI Search (ChatGPT, etc)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Social Media'  id='choice_6_72_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_7' id='label_6_72_7' class='gform-field-label gform-field-label--type-inline'>Social Media<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Radio Ad'  id='choice_6_72_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_8' id='label_6_72_8' class='gform-field-label gform-field-label--type-inline'>Radio Ad<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_72_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Other'  id='choice_6_72_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_72_9' id='label_6_72_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_101\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Note: Please ensure all the details entered are accurate before submitting, as they cannot be changed afterward unless updated by your counselor or an administrator.<\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input 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