{"id":423,"date":"2021-02-12T10:18:40","date_gmt":"2021-02-12T10:18:40","guid":{"rendered":"https:\/\/demosites.io\/neve-3\/?page_id=7"},"modified":"2023-11-01T11:25:42","modified_gmt":"2023-11-01T15:25:42","slug":"7b3c2-typography","status":"publish","type":"page","link":"https:\/\/impactstlc.org\/?page_id=423","title":{"rendered":"Preliminary Registration"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-b89d63ef-1ea3-466e-8565-935821a47bc4\" id=\"wpforms-494\"><form id=\"wpforms-form-494\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"494\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F423&#038;wpforms_form_id=494\" data-token=\"7e3930d4acc15635f9620bd31e6ab787\" data-token-time=\"1778907558\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-494-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_19\">Client Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" required><\/div><div id=\"wpforms-494-field_53-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_53\">Client Social Security Number (no dashes, no spaces) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-494-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" required><\/div><div id=\"wpforms-494-field_64-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_64\">Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-494-field_64\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][64][address1]\" ><label for=\"wpforms-494-field_64\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-494-field_64-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][64][address2]\" ><label for=\"wpforms-494-field_64-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-494-field_64-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][64][city]\" ><label for=\"wpforms-494-field_64-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-494-field_64-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][64][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>Florida<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-494-field_64-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-494-field_64-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][64][postal]\" ><label for=\"wpforms-494-field_64-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-494-field_69-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_69\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-494-field_69\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][69][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-494-field_79-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_79\">Gender? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_79\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_79_1\" name=\"wpforms[fields][79]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_79_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_79_2\" name=\"wpforms[fields][79]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_79_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_80-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_80\">Diagnosis(es), i.e. Autism, Aspergers, ODD, Pica, etc.? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_80\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][80]\" required><\/div><div id=\"wpforms-494-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_12\">Estimated Grade Level <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-494-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_16\">Previous Behavioral Discharge? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_16_2\" name=\"wpforms[fields][16][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_16_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_20\">Medication? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" required><div class=\"wpforms-field-description\">Please respond n\/a if not applicable.<\/div><\/div><div id=\"wpforms-494-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_18\">Medication administered during business hours? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_18_2\" name=\"wpforms[fields][18][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_18_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_50\">Does client have allergies?  If so, what is he\/she allergic to? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_50\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][50]\" required><div class=\"wpforms-field-description\">Please respond n\/a if not applicable.<\/div><\/div><div id=\"wpforms-494-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_49\">Does client have seizures? If so, date of last seizure? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_49\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][49]\" required><div class=\"wpforms-field-description\">Please respond n\/a if not applicable.<\/div><\/div><div id=\"wpforms-494-field_78-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_78\">Client Support Services? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_78_1\" name=\"wpforms[fields][78]\" value=\"Medicaid Waiver\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_78_1\">Medicaid Waiver<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_78_2\" name=\"wpforms[fields][78]\" value=\"AHCA\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_78_2\">AHCA<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_78_3\" name=\"wpforms[fields][78]\" value=\"Private Pay\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_78_3\">Private Pay<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_74\">Please provide service authorization number:<\/label><input type=\"text\" id=\"wpforms-494-field_74\" class=\"wpforms-field-medium\" name=\"wpforms[fields][74]\" ><\/div><div id=\"wpforms-494-field_82-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_82\">Please upload Service Authorization letter.<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"82\"\n\t\tdata-form-id=\"494\"\n\t\tdata-input-name=\"wpforms_494_82\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"2097152\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"2097152\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-494-field_82\"\n\t\tname=\"wpforms_494_82\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-494-field_75-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_75\">Does the client have transportation approval included in services?<\/label><ul id=\"wpforms-494-field_75\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_75_1\" name=\"wpforms[fields][75]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_75_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-494-field_75_2\" name=\"wpforms[fields][75]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_75_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_76-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_76\">Support Coordinator&#039;s Name (if applicable)<\/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-494-field_76\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][76][first]\" ><label for=\"wpforms-494-field_76\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-494-field_76-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][76][last]\" ><label for=\"wpforms-494-field_76-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-494-field_77-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_77\">Support Coordinator&#039;s Phone<\/label><input type=\"tel\" id=\"wpforms-494-field_77\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][77]\" aria-label=\"Support Coordinator&#039;s Phone\" ><\/div><div id=\"wpforms-494-field_83-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_83\">Please upload Support Plan.<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"83\"\n\t\tdata-form-id=\"494\"\n\t\tdata-input-name=\"wpforms_494_83\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"2097152\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"2097152\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-494-field_83\"\n\t\tname=\"wpforms_494_83\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-494-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_27\">Insurance Provider <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required><div class=\"wpforms-field-description\">Please respond n\/a if not applicable.<\/div><\/div><div id=\"wpforms-494-field_29-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_29\">Policy Number<\/label><input type=\"number\" id=\"wpforms-494-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-494-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_34\">Parent\/Guardian <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" required><\/div><div id=\"wpforms-494-field_36-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_36\">Parent\/Guardian Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-494-field_36\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][36]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-494-field_37-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_37\">Alternate Email <\/label><input type=\"email\" id=\"wpforms-494-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" spellcheck=\"false\" ><\/div><div id=\"wpforms-494-field_62-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_62\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-494-field_62\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][62][address1]\" required><label for=\"wpforms-494-field_62\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-494-field_62-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][62][address2]\" ><label for=\"wpforms-494-field_62-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-494-field_62-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][62][city]\" required><label for=\"wpforms-494-field_62-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-494-field_62-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][62][state]\" required><option class=\"placeholder\" value=\"\" selected disabled>Florida<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-494-field_62-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-494-field_62-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][62][postal]\" required><label for=\"wpforms-494-field_62-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-494-field_66-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_66\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-494-field_66\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][66]\" aria-label=\"Phone\" required><\/div><div id=\"wpforms-494-field_67-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_67\">Alternate Phone<\/label><input type=\"tel\" id=\"wpforms-494-field_67\" class=\"wpforms-field-medium wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][67]\" aria-label=\"Alternate Phone\" ><\/div><div id=\"wpforms-494-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_60\">Emergency Contact <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_60\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][60]\" required><\/div><div id=\"wpforms-494-field_68-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_68\">Emergency Contact Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-494-field_68\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][68]\" aria-label=\"Emergency Contact Phone\" required><\/div><div id=\"wpforms-494-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_15\">Are you interested in before\/after hours? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_15_2\" name=\"wpforms[fields][15][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_15_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_44-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_44\">Communication Skills? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_44_1\" name=\"wpforms[fields][44][]\" value=\"Highly Verbal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_44_1\">Highly Verbal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_44_2\" name=\"wpforms[fields][44][]\" value=\"Semi-Verbal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_44_2\">Semi-Verbal<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_44_3\" name=\"wpforms[fields][44][]\" value=\"Non-Verbal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_44_3\">Non-Verbal<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_44_4\" name=\"wpforms[fields][44][]\" value=\"American Sign Language\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_44_4\">American Sign Language<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_45-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_45\">Feeding Skills <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_45_1\" name=\"wpforms[fields][45][]\" value=\"Independent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_45_1\">Independent<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_45_2\" name=\"wpforms[fields][45][]\" value=\"Needs Assistance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_45_2\">Needs Assistance<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_45_3\" name=\"wpforms[fields][45][]\" value=\"Hand over Hand\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_45_3\">Hand over Hand<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_81-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_81\">Dietary Restrictions, if any?<\/label><input type=\"text\" id=\"wpforms-494-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" ><\/div><div id=\"wpforms-494-field_43-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_43\">Bathroom Skills? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_43_1\" name=\"wpforms[fields][43][]\" value=\"Independent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_43_1\">Independent<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_43_2\" name=\"wpforms[fields][43][]\" value=\"Needs Assistance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_43_2\">Needs Assistance<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_43_3\" name=\"wpforms[fields][43][]\" value=\"Untrained\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_43_3\">Untrained<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_46-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_46\">Elopement Issues? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_46_1\" name=\"wpforms[fields][46][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_46_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_46_2\" name=\"wpforms[fields][46][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_46_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_47-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_47\">Physical Aggression? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_47_1\" name=\"wpforms[fields][47][]\" value=\"Self-Injurious\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_47_1\">Self-Injurious<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_47_2\" name=\"wpforms[fields][47][]\" value=\"Aggressive towards others\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_47_2\">Aggressive towards others<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_47_3\" name=\"wpforms[fields][47][]\" value=\"Disruptive Behaviors\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_47_3\">Disruptive Behaviors<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_47_4\" name=\"wpforms[fields][47][]\" value=\"N\/A\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_47_4\">N\/A<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_52\">Client interests, including favorite things? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_52\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][52]\" required><\/div><div id=\"wpforms-494-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_54\">Does client enjoy social interaction with caregivers and peers? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-494-field_54\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][54]\" required><\/div><div id=\"wpforms-494-field_57-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_57\">Job Skill Level <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-494-field_57\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_57_1\" name=\"wpforms[fields][57][]\" value=\"Independent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_57_1\">Independent<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_57_2\" name=\"wpforms[fields][57][]\" value=\"With prompting\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_57_2\">With prompting<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-494-field_57_3\" name=\"wpforms[fields][57][]\" value=\"Hand over Hand \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-494-field_57_3\">Hand over Hand<\/label><\/li><\/ul><\/div><div id=\"wpforms-494-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_58\">Previous Work Experience<\/label><input type=\"text\" id=\"wpforms-494-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" ><\/div><div id=\"wpforms-494-field_59-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-494-field_59\">Parent\/Guardian goals for client? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-494-field_59\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][59]\" required><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"494\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/impactstlc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F423\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-494\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/impactstlc.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"neve_meta_sidebar":"full-width","neve_meta_container":"","neve_meta_enable_content_width":"on","neve_meta_content_width":60,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"off","footnotes":""},"class_list":["post-423","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages\/423","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/impactstlc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=423"}],"version-history":[{"count":8,"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages\/423\/revisions"}],"predecessor-version":[{"id":661,"href":"https:\/\/impactstlc.org\/index.php?rest_route=\/wp\/v2\/pages\/423\/revisions\/661"}],"wp:attachment":[{"href":"https:\/\/impactstlc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=423"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}