{"id":9054,"date":"2025-07-16T09:14:39","date_gmt":"2025-07-16T13:14:39","guid":{"rendered":"https:\/\/kristawilliamsonrd.com\/?page_id=9054"},"modified":"2025-07-16T19:58:48","modified_gmt":"2025-07-16T23:58:48","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/kristawilliamsonrd.com\/index.php\/referral-form\/","title":{"rendered":"Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9054\" class=\"elementor elementor-9054\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bc8b41c e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-column-slider-no wpr-equal-height-no e-con e-parent\" data-id=\"bc8b41c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-93c8cc7 elementor-widget elementor-widget-wpforms\" data-id=\"93c8cc7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-9047\"><form id=\"wpforms-form-9047\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"9047\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/9054\" data-token=\"cd892243140078daa2d3a4746de09ad8\" data-token-time=\"1778244369\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\">\t\t<div id=\"wpforms-9047-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-9047-field_2\" >for Relevant Healthcare<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-9047-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-9047-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Client Name: <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-9047-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-9047-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-9047-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-9047-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-9047-field_10-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"10\"><label class=\"wpforms-field-label\">Client&#039;s Preferred Contact Method: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-9047-field_10\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9047-field_10_1\" name=\"wpforms[fields][10][]\" value=\"Email\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9047-field_10_1\">Email<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9047-field_10_2\" name=\"wpforms[fields][10][]\" value=\"Phone Call\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9047-field_10_2\">Phone Call<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-9047-field_10_3\" name=\"wpforms[fields][10][]\" value=\"Text Message\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9047-field_10_3\">Text Message<\/label><\/li><\/ul><\/div><div id=\"wpforms-9047-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_15\">Client&#039;s Contact Information: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9047-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" required><\/div><div id=\"wpforms-9047-field_7-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_7\">Reason for Referral: <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-9047-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/textarea><\/div><div id=\"wpforms-9047-field_11-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_11\">Relevant Medical History &amp; Additional Notes:<\/label><textarea id=\"wpforms-9047-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" ><\/textarea><\/div><div id=\"wpforms-9047-field_8-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_8\">Referral Priority<\/label><select id=\"wpforms-9047-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\"><option value=\"Normal\"  class=\"choice-1 depth-1\"  >Normal<\/option><option value=\"Urgent\"  class=\"choice-2 depth-1\"  >Urgent<\/option><\/select><\/div><div id=\"wpforms-9047-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_5\">Referring Healthcare Provider&#039;s Name: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9047-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" required><\/div><div id=\"wpforms-9047-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_6\">Referring Healthcare Provider&#039;s Contact Number:<\/label><input type=\"text\" id=\"wpforms-9047-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" ><\/div><div id=\"wpforms-9047-field_12-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"12\"><label class=\"wpforms-field-label\">Would you like me to fax a copy of my session notes for your records? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-9047-field_12\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9047-field_12_1\" name=\"wpforms[fields][12][]\" value=\"Yes, please\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9047-field_12_1\">Yes, please<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9047-field_12_2\" name=\"wpforms[fields][12][]\" value=\"No, thank you\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9047-field_12_2\">No, thank you<\/label><\/li><\/ul><\/div><div id=\"wpforms-9047-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-9047-field_14\">If yes, please provide your Fax Number:<\/label><input type=\"text\" id=\"wpforms-9047-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-9047-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-9047-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-9047-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"9047\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/pages\/9054\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-9047\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit Referral\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit Referral<\/button><img decoding=\"async\" src=\"https:\/\/kristawilliamsonrd.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-799e7fe elementor-widget elementor-widget-spacer\" data-id=\"799e7fe\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\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","protected":false},"excerpt":{"rendered":"<p>Please enable JavaScript in your browser to complete this form.Client Name: *FirstLastClient&#039;s Preferred Contact Method: * Email Phone Call Text Message Client&#039;s Contact Information: *Reason for Referral: *Relevant Medical History &amp; Additional Notes:Referral PriorityNormalUrgentReferring Healthcare Provider&#039;s Name: *Referring Healthcare Provider&#039;s Contact Number:Would you like me to fax a copy of my session notes for your records? * Yes, please No, thank you If yes, please provide your Fax Number: Submit Referral<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-9054","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/pages\/9054","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/comments?post=9054"}],"version-history":[{"count":0,"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/pages\/9054\/revisions"}],"wp:attachment":[{"href":"https:\/\/kristawilliamsonrd.com\/index.php\/wp-json\/wp\/v2\/media?parent=9054"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}