{"id":40,"date":"2015-07-24T22:35:40","date_gmt":"2015-07-24T22:35:40","guid":{"rendered":"http:\/\/build7-20-15.openarmsprp.com\/?page_id=40"},"modified":"2022-03-15T15:26:08","modified_gmt":"2022-03-15T15:26:08","slug":"referrals","status":"publish","type":"page","link":"https:\/\/openarmsprp.com\/index.php\/referrals\/","title":{"rendered":"Referrals"},"content":{"rendered":"<div class=\"ezcol ezcol-one-third\">\n<h3 style=\"text-align: center;\">Form Instructions<\/h3>\n<p>Please fill in all the form fields as accurately as possible. If there is missing or incomplete information, it may cause a delay in processing your referral information.<\/p>\n<p>You have two options to submit a referral to us.<\/p>\n<p>It can be printed, completed and faxed to<br \/>\n(667) 309-3161\u00a0\u00a0\u00a0\u00a0 ATTN: Chania Brooks<\/p>\n<p>or scanned and emailed to <a href=\"mailto:info@openarmsprp.com\">info@openarmsprp.com<\/a><\/p>\n<p><em><strong><a href=\"\/wp-content\/uploads\/2015\/08\/Open-Arms-Referral-Form1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Click Here to Print<\/a><\/strong><\/em><\/p>\n<p>Fill in the form to the right and submit it through our website<\/p>\n<p>For questions about completing this form or inquiries about our services please call (667) 239-3195 or email and a program representative will reply within 1 business day.<\/p>\n<p><a href=\"https:\/\/openarmsprp.com\/wp-content\/uploads\/2019\/06\/ssl-security-badge.png\" data-rel=\"prettyPhoto[40]\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-medium wp-image-195\" src=\"https:\/\/openarmsprp.com\/wp-content\/uploads\/2019\/06\/ssl-security-badge-288x300.png\" alt=\"\" width=\"288\" height=\"300\" srcset=\"https:\/\/openarmsprp.com\/wp-content\/uploads\/2019\/06\/ssl-security-badge-288x300.png 288w, https:\/\/openarmsprp.com\/wp-content\/uploads\/2019\/06\/ssl-security-badge.png 400w\" sizes=\"(max-width: 288px) 100vw, 288px\" \/><\/a><br \/>\n<\/div>\n<div class=\"ezcol ezcol-two-third ezcol-last\">\n<h3 style=\"text-align: center;\">Referral Form<\/h3>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/index.php\/wp-json\/wp\/v2\/pages\/40#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_1_1\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><label class='gfield_label gform-field-label' for='input_1_1' >Referral Date:<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_1' id='input_1_1' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_1_1_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_1_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_1' class='gform_hidden' value='https:\/\/openarmsprp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_13\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><br \/><br \/>\n<h3>Client Information<\/h3><\/li><li id=\"field_1_2\"  class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><label class='gfield_label gform-field-label' for='input_1_2' >Client 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_2' id='input_1_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_3\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><label class='gfield_label gform-field-label'  >Gender:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_3'>\n\t\t\t<li class='gchoice gchoice_1_3_0'>\n\t\t\t\t<input name='input_3' type='radio' value='Male'  id='choice_1_3_0'    \/>\n\t\t\t\t<label for='choice_1_3_0' id='label_1_3_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_3_1'>\n\t\t\t\t<input name='input_3' type='radio' value='Female'  id='choice_1_3_1'    \/>\n\t\t\t\t<label for='choice_1_3_1' id='label_1_3_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_4\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\"><label class='gfield_label gform-field-label' for='input_1_4' >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_4' id='input_1_4' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_1_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_4_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_4' class='gform_hidden' value='https:\/\/openarmsprp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_5\"  class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label gform-field-label' for='input_1_5' >Medical Assistance #:<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='small'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\"  class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><label class='gfield_label gform-field-label' for='input_1_6' >Race:<\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='medium gfield_select'     aria-invalid=\"false\" ><option value='African American' >African American<\/option><option value='Caucasian' >Caucasian<\/option><option value='Asian' >Asian<\/option><option value='Spanish Descent' >Spanish Descent<\/option><option value='Native American' >Native American<\/option><\/select><\/div><\/li><li id=\"field_1_7\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \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_1_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_1_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_7_1' id='input_1_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_1_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_7_2' id='input_1_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_1_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_7_3' id='input_1_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_7_4_container' >\n                                        <select name='input_7.4' id='input_1_7_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_1_7_4' id='input_1_7_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_1_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_7_5' id='input_1_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_1_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_12\"  class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><label class='gfield_label gform-field-label' for='input_1_12' >Home Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_1_12' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_15\"  class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><label class='gfield_label gform-field-label' for='input_1_15' >Cell Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_16\"  class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><label class='gfield_label gform-field-label' for='input_1_16' >Work Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_1_16' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_9\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label'  >Does &quot;Client&quot; have a legal guardian?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_9'>\n\t\t\t<li class='gchoice gchoice_1_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='yes'  id='choice_1_9_0'    \/>\n\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='no'  id='choice_1_9_1'    \/>\n\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_8\"  class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Legal Guardian Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_10\"  class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label gform-field-label' for='input_1_10' >Legal Guardian Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_11\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Legal Guardian Address<\/label>    \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_1_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_1_11_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_11_1' id='input_1_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_11_2_container' >\n                                        <input type='text' name='input_11.2' id='input_1_11_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_11_2' id='input_1_11_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_1_11_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_11_3' id='input_1_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_11_4_container' >\n                                        <select name='input_11.4' id='input_1_11_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                                        <label for='input_1_11_4' id='input_1_11_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_1_11_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_11_5' id='input_1_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_1_11_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_14\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><br \/><br \/>\n<h3>Referral Information<\/h3><\/li><li id=\"field_1_17\"  class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\"><label class='gfield_label gform-field-label' for='input_1_17' >Referring Agency\/Therapist:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_18\"  class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><label class='gfield_label gform-field-label' for='input_1_18' >Credentials:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_19\"  class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label' for='input_1_19' >Phone#<\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_1_19' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_20\"  class=\"gfield gfield--type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label' for='input_1_20' >Fax#<\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_1_20' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_21\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><label class='gfield_label gform-field-label' for='input_1_21' >Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_1_21' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_44\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\"><br \/><br \/><\/li><li id=\"field_1_22\"  class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><label class='gfield_label gform-field-label' for='input_1_22' >Clinical Supervisor\u2019s Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_23\"  class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><label class='gfield_label gform-field-label' for='input_1_23' >Credentials:<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_24\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><label class='gfield_label gform-field-label' for='input_1_24' >School:<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_25\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Clinical Supervisor\u2019s Address:<\/label>    \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_1_25' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_25_1_container' >\n                                        <input type='text' name='input_25.1' id='input_1_25_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_25_1' id='input_1_25_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_25_2_container' >\n                                        <input type='text' name='input_25.2' id='input_1_25_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_25_2' id='input_1_25_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_25_3_container' >\n                                    <input type='text' name='input_25.3' id='input_1_25_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_25_3' id='input_1_25_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_25_4_container' >\n                                        <select name='input_25.4' id='input_1_25_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                                        <label for='input_1_25_4' id='input_1_25_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_25_5_container' >\n                                    <input type='text' name='input_25.5' id='input_1_25_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_25_5' id='input_1_25_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_25.6' id='input_1_25_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_26\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_label gform-field-label' for='input_1_26' >Clinical Supervisor\u2019s Phone#:<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_1_26' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_45\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\"><br \/><br \/><\/li><li id=\"field_1_27\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><label class='gfield_label gform-field-label' for='input_1_27' >Primary Care Physician:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_28\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Primary Care Physician  Address:<\/label>    \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_1_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_1_28_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_28_1' id='input_1_28_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_28_2_container' >\n                                        <input type='text' name='input_28.2' id='input_1_28_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_28_2' id='input_1_28_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_1_28_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_28_3' id='input_1_28_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_28_4_container' >\n                                        <select name='input_28.4' id='input_1_28_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                                        <label for='input_1_28_4' id='input_1_28_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_1_28_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_28_5' id='input_1_28_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_1_28_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_29\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label gform-field-label' for='input_1_29' >Primary Care Physician Phone#:<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_1_29' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_30\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><br \/><br \/>\n<h3>Diagnosis<\/h3><\/li><li id=\"field_1_31\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label gform-field-label' for='input_1_31' >DSM-5 Diagnosis:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_1_31' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_32\"  class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><label class='gfield_label gform-field-label' for='input_1_32' >Diagnosis Given By:<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_33\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><label class='gfield_label gform-field-label' for='input_1_33' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_33' id='input_1_33' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_33_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_33_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_33' class='gform_hidden' value='https:\/\/openarmsprp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_46\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\"><br \/><br \/><\/li><li id=\"field_1_34\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please check Reason for Referral:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_34'><li class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Self-Care Training'  id='choice_1_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Self-Care Training<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Family Support'  id='choice_1_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2' class='gform-field-label gform-field-label--type-inline'>Family Support<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Anger Management Skills'  id='choice_1_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_3' id='label_1_34_3' class='gform-field-label gform-field-label--type-inline'>Anger Management Skills<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Social\/Interpersonal Skill Development'  id='choice_1_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_4' id='label_1_34_4' class='gform-field-label gform-field-label--type-inline'>Social\/Interpersonal Skill Development<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='Medication Monitoring'  id='choice_1_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_5' id='label_1_34_5' class='gform-field-label gform-field-label--type-inline'>Medication Monitoring<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.6' type='checkbox'  value='Independent Living \/Life Skills Training'  id='choice_1_34_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_6' id='label_1_34_6' class='gform-field-label gform-field-label--type-inline'>Independent Living \/Life Skills Training<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.7' type='checkbox'  value='Illness Management'  id='choice_1_34_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_7' id='label_1_34_7' class='gform-field-label gform-field-label--type-inline'>Illness Management<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.8' type='checkbox'  value='Suicidal\/Homicidal Risk'  id='choice_1_34_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_8' id='label_1_34_8' class='gform-field-label gform-field-label--type-inline'>Suicidal\/Homicidal Risk<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.9' type='checkbox'  value='Conflict Resolution'  id='choice_1_34_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_9' id='label_1_34_9' class='gform-field-label gform-field-label--type-inline'>Conflict Resolution<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_35\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><label class='gfield_label gform-field-label' for='input_1_35' >Please describe in detail the specific description of clients Reason for Referral and Symptoms and Behaviors that apply to the clients DSM-5 Diagnosis:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_1_35' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_36\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><label class='gfield_label gform-field-label'  >Is client on medication?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_36'>\n\t\t\t<li class='gchoice gchoice_1_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_1_36_0'    \/>\n\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_1_36_1'    \/>\n\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_37\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><label class='gfield_label gform-field-label' for='input_1_37' >List medication and dosage:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_1_37' class='textarea medium'  aria-describedby=\"gfield_description_1_37\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_37'>One per Line<\/div><\/li><li id=\"field_1_39\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label'  >History of hospitalizations:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_39'>\n\t\t\t<li class='gchoice gchoice_1_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_1_39_0'    \/>\n\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_1_39_1'    \/>\n\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_40\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\"><label class='gfield_label gform-field-label' for='input_1_40' >Indicate place and date of hospitalization:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_1_40' class='textarea medium'  aria-describedby=\"gfield_description_1_40\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_40'>One per Line<\/div><\/li><li id=\"field_1_41\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label gform-field-label' for='input_1_41' >List known medical history:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_1_41' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_43\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><br \/><br \/>\n<b>Please Type your full name as your digital signature. Complete the captcha and click the 'Submit' button<\/b><\/li><li id=\"field_1_42\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='input_1_42' >Referral Source\u2019s Signature:<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_1_42' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_50\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\"><br \/><br \/><\/li><li id=\"field_1_51\"  class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\"><label class='gfield_label gform-field-label' for='input_1_51' >CAPTCHA<\/label><div id='input_1_51' class='ginput_container ginput_recaptcha' data-sitekey='6LdqkqQUAAAAAOsSPeqnbnMHDWWuzsOI0RDG5h2B'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><li id=\"field_1_49\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\"><br \/><br \/><\/li><li id=\"field_1_52\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\"><label class='gfield_label gform-field-label' for='input_1_52' >Phone<\/label><div class='ginput_container'><input name='input_52' id='input_1_52' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_52'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=1&amp;title=&amp;description=&amp;tabindex=0&amp;theme=data-form-theme=&#039;legacy&#039;' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsImI2NTI0ZTVhNTJhMWM0ZGU3ZTZmZGE5ODk3MDFhNjE5Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_1' id='gform_ajax_frame_1' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/openarmsprp.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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