{"id":2976,"date":"2016-08-09T13:47:03","date_gmt":"2016-08-09T17:47:03","guid":{"rendered":"http:\/\/depts.washington.edu\/uwautism\/?page_id=2976"},"modified":"2021-11-12T08:38:55","modified_gmt":"2021-11-12T16:38:55","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/depts.washington.edu\/uwautism\/clinical-services\/intake-form\/","title":{"rendered":"Registration Form"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var 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),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Registration Form<\/h3>\n                            <span class='gform_description'><\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/uwautism\/wp-json\/wp\/v2\/pages\/2976#gf_2' novalidate>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>9<\/span> - Patient Information\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_2_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_122\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Are you currently located in the European Union (EU)?<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_2_122'>\n\t\t\t<li class='gchoice gchoice_2_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes' checked='checked' id='choice_2_122_0'    \/>\n\t\t\t\t<label for='choice_2_122_0' id='label_2_122_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_2_122_1'    \/>\n\t\t\t\t<label for='choice_2_122_1' id='label_2_122_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_124\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >I have read and understood the UW&#039;s Privacy Policy with respect to EU entities<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_124'><li class='gchoice gchoice_2_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='Yes'  id='choice_2_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_124_1' id='label_2_124_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_123\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><a href = \"http:\/\/www.washington.edu\/online\/privacy\/\"> Click here to view UW Privacy Policy <\/a><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_125' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_176\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><strong> NOTE: Our Tacoma branch is not currently offering ABA services. <\/strong><\/li><li id=\"field_2_1\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Patient Information<\/h2><\/li><li id=\"field_2_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_2_5'>\n                            \n                            <span id='input_2_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_2_5_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_2_5_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_2_5_4_container' class='name_middle' >\n                                                    <input type='text' name='input_5.4' id='input_2_5_4' value='' aria-label='Middle name'   aria-required='false'     \/>\n                                                    <label for='input_2_5_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_2_5_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_2_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_2_7' class='ginput_container ginput_complex'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date' id='input_2_7_1_container'>\n                                            <input type='number'  name='input_7[]' id='input_2_7_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_7_1' class='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_2_7_2_container'>\n                                            <input type='number'  name='input_7[]' id='input_2_7_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_7_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_2_7_3_container'>\n                                            <input type='number'  name='input_7[]' id='input_2_7_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_2_7_3' class='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><div class='gfield_description' id='gfield_description_2_7'>NOTE: UWAC is not accepting requests for adult (18+) diagnostic evaluations at this time<\/div><\/li><li id=\"field_2_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_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 has_country ginput_container_address' id='input_2_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_2_12_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_12_1' id='input_2_12_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_2_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_2_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_12_2' id='input_2_12_2_label' >Apartment #<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_2_12_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_12_3' id='input_2_12_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_2_12_4' value='WA'      aria-required='true'    \/>\n                                        <label for='input_2_12_4' id='input_2_12_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_2_12_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_12_5' id='input_2_12_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_2_12_6_container' >\n                                        <select name='input_12.6' id='input_2_12_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_12_6' id='input_2_12_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_93\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Ethnicity Category<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_93'>\n\t\t\t<li class='gchoice gchoice_2_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Asian'  id='choice_2_93_0'    \/>\n\t\t\t\t<label for='choice_2_93_0' id='label_2_93_0'>Asian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='African American'  id='choice_2_93_1'    \/>\n\t\t\t\t<label for='choice_2_93_1' id='label_2_93_1'>African American<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_2'>\n\t\t\t\t<input name='input_93' type='radio' value='White'  id='choice_2_93_2'    \/>\n\t\t\t\t<label for='choice_2_93_2' id='label_2_93_2'>White<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_3'>\n\t\t\t\t<input name='input_93' type='radio' value='Hispanic'  id='choice_2_93_3'    \/>\n\t\t\t\t<label for='choice_2_93_3' id='label_2_93_3'>Hispanic<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_4'>\n\t\t\t\t<input name='input_93' type='radio' value='Native American'  id='choice_2_93_4'    \/>\n\t\t\t\t<label for='choice_2_93_4' id='label_2_93_4'>Native American<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_5'>\n\t\t\t\t<input name='input_93' type='radio' value='Pacific Islander'  id='choice_2_93_5'    \/>\n\t\t\t\t<label for='choice_2_93_5' id='label_2_93_5'>Pacific Islander<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_6'>\n\t\t\t\t<input name='input_93' type='radio' value='gf_other_choice'  id='choice_2_93_6'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_93_other' name='input_93_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_93'>If of more than one ethnicity, please specify all.<\/div><\/li><li id=\"field_2_177\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_177' >Specific Ethnicity\/Race<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_2_177' type='text' value='' class='large' maxlength='512' aria-describedby=\"gfield_description_2_177\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_2_177'>How would you like us to refer to your child's ethnicity\/race (e.g. of a specific country\/nation name, mixed\/multi, Asian vs. Asian-American, etc.)?<\/div><\/li><li id=\"field_2_31\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_31' >Last Four Digits of SSN<\/label><div class='ginput_container ginput_container_number'><input name='input_31' id='input_2_31' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_94\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_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_2_94'>\n\t\t\t<li class='gchoice gchoice_2_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Boy\/Man'  id='choice_2_94_0'    \/>\n\t\t\t\t<label for='choice_2_94_0' id='label_2_94_0'>Boy\/Man<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Girl\/Woman'  id='choice_2_94_1'    \/>\n\t\t\t\t<label for='choice_2_94_1' id='label_2_94_1'>Girl\/Woman<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_94_2'>\n\t\t\t\t<input name='input_94' type='radio' value='Non-Binary'  id='choice_2_94_2'    \/>\n\t\t\t\t<label for='choice_2_94_2' id='label_2_94_2'>Non-Binary<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_94_3'>\n\t\t\t\t<input name='input_94' type='radio' value='Prefer Not To Say'  id='choice_2_94_3'    \/>\n\t\t\t\t<label for='choice_2_94_3' id='label_2_94_3'>Prefer Not To Say<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_148\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Would you like to further specify the client&#039;s pronouns, etc.?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_148'>\n\t\t\t<li class='gchoice gchoice_2_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='Yes'  id='choice_2_148_0'    \/>\n\t\t\t\t<label for='choice_2_148_0' id='label_2_148_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_2_148_1'    \/>\n\t\t\t\t<label for='choice_2_148_1' id='label_2_148_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_164\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Start of Supplemental Gender Section<\/h2><\/li><li id=\"field_2_149\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_149' >Preferred\/True Name<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_2_149' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_150\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_150' >Legal Name<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_2_150' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_151\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_151' >Pronouns (e.g. he\/him, she\/her, they\/them, xe\/xem):<\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_2_151' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_154\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_154' >Assigned pronouns:<\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_2_154' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_156\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >How would the client like to be referred to in clinical reports?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_156'>\n\t\t\t<li class='gchoice gchoice_2_156_0'>\n\t\t\t\t<input name='input_156' type='radio' value='Transgender'  id='choice_2_156_0'    \/>\n\t\t\t\t<label for='choice_2_156_0' id='label_2_156_0'>Transgender<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_156_1'>\n\t\t\t\t<input name='input_156' type='radio' value='Nonbinary'  id='choice_2_156_1'    \/>\n\t\t\t\t<label for='choice_2_156_1' id='label_2_156_1'>Nonbinary<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_156_2'>\n\t\t\t\t<input name='input_156' type='radio' value='gf_other_choice'  id='choice_2_156_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_156_other' name='input_156_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_155\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >How would the client like to be referred to in clinical reports?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_155'>\n\t\t\t<li class='gchoice gchoice_2_155_0'>\n\t\t\t\t<input name='input_155' type='radio' value='Individual'  id='choice_2_155_0'    \/>\n\t\t\t\t<label for='choice_2_155_0' id='label_2_155_0'>Individual<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_155_1'>\n\t\t\t\t<input name='input_155' type='radio' value='Male'  id='choice_2_155_1'    \/>\n\t\t\t\t<label for='choice_2_155_1' id='label_2_155_1'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_155_2'>\n\t\t\t\t<input name='input_155' type='radio' value='Female'  id='choice_2_155_2'    \/>\n\t\t\t\t<label for='choice_2_155_2' id='label_2_155_2'>Female<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_155_3'>\n\t\t\t\t<input name='input_155' type='radio' value='Person'  id='choice_2_155_3'    \/>\n\t\t\t\t<label for='choice_2_155_3' id='label_2_155_3'>Person<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_155_4'>\n\t\t\t\t<input name='input_155' type='radio' value='gf_other_choice'  id='choice_2_155_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_155_other' name='input_155_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_159\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >How would the client like to be referred to in the waiting room?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_159'><li class='gchoice gchoice_2_159_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.1' type='checkbox'  value='Preferred\/True name'  id='choice_2_159_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_159_1' id='label_2_159_1'>Preferred\/True name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_159_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.2' type='checkbox'  value='Legal name'  id='choice_2_159_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_159_2' id='label_2_159_2'>Legal name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_159_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.3' type='checkbox'  value='Preferred\/True pronouns'  id='choice_2_159_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_159_3' id='label_2_159_3'>Preferred\/True pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_159_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.4' type='checkbox'  value='Assigned pronouns'  id='choice_2_159_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_159_4' id='label_2_159_4'>Assigned pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_160\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >How would the client like to be referred to in their clinical report?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_160'><li class='gchoice gchoice_2_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Preferred\/True name'  id='choice_2_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_160_1' id='label_2_160_1'>Preferred\/True name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='Legal name'  id='choice_2_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_160_2' id='label_2_160_2'>Legal name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_160_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.3' type='checkbox'  value='Preferred\/True pronouns'  id='choice_2_160_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_160_3' id='label_2_160_3'>Preferred\/True pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_160_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.4' type='checkbox'  value='Assigned pronouns'  id='choice_2_160_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_160_4' id='label_2_160_4'>Assigned pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_161\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >How would the client like to be referred to when talking to their family?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_161'><li class='gchoice gchoice_2_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Preferred\/True name'  id='choice_2_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_161_1' id='label_2_161_1'>Preferred\/True name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='Legal name'  id='choice_2_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_161_2' id='label_2_161_2'>Legal name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_161_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.3' type='checkbox'  value='Preferred\/True pronouns'  id='choice_2_161_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_161_3' id='label_2_161_3'>Preferred\/True pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_161_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.4' type='checkbox'  value='Assigned pronouns'  id='choice_2_161_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_161_4' id='label_2_161_4'>Assigned pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_162\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >How should clinicians refer to the client with other professionals (e.g. prescribers)?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_162'><li class='gchoice gchoice_2_162_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.1' type='checkbox'  value='Preferred\/True name'  id='choice_2_162_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_162_1' id='label_2_162_1'>Preferred\/True name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_162_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.2' type='checkbox'  value='Legal Name'  id='choice_2_162_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_162_2' id='label_2_162_2'>Legal Name<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_162_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.3' type='checkbox'  value='Preferred\/True pronouns'  id='choice_2_162_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_162_3' id='label_2_162_3'>Preferred\/True pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_162_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.4' type='checkbox'  value='Assigned pronouns'  id='choice_2_162_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_162_4' id='label_2_162_4'>Assigned pronouns<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_163\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_163' >Is there anything else you would like us to know about the client&#039;s gender?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_163' id='input_2_163' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_165\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">End of Supplemental Gender Section<\/h2><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_103' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_103' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_14\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Person Completing this Form<\/h2><\/li><li id=\"field_2_15\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_15'>\n                            \n                            <span id='input_2_15_3_container' class='name_first' >\n                                                    <input type='text' name='input_15.3' id='input_2_15_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_2_15_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_15_6_container' class='name_last' >\n                                                    <input type='text' name='input_15.6' id='input_2_15_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_2_15_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_16' >Relationship to patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_173\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Caregiver Category<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_173'>\n\t\t\t<li class='gchoice gchoice_2_173_0'>\n\t\t\t\t<input name='input_173' type='radio' value='Biological Parent(s)'  id='choice_2_173_0'    \/>\n\t\t\t\t<label for='choice_2_173_0' id='label_2_173_0'>Biological Parent(s)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_173_1'>\n\t\t\t\t<input name='input_173' type='radio' value='Foster Parent(s)'  id='choice_2_173_1'    \/>\n\t\t\t\t<label for='choice_2_173_1' id='label_2_173_1'>Foster Parent(s)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_173_2'>\n\t\t\t\t<input name='input_173' type='radio' value='Grandparent(s)'  id='choice_2_173_2'    \/>\n\t\t\t\t<label for='choice_2_173_2' id='label_2_173_2'>Grandparent(s)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_173_3'>\n\t\t\t\t<input name='input_173' type='radio' value='Legal Guardian'  id='choice_2_173_3'    \/>\n\t\t\t\t<label for='choice_2_173_3' id='label_2_173_3'>Legal Guardian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_173_4'>\n\t\t\t\t<input name='input_173' type='radio' value='Other Relatives'  id='choice_2_173_4'    \/>\n\t\t\t\t<label for='choice_2_173_4' id='label_2_173_4'>Other Relatives<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_173_5'>\n\t\t\t\t<input name='input_173' type='radio' value='Other'  id='choice_2_173_5'    \/>\n\t\t\t\t<label for='choice_2_173_5' id='label_2_173_5'>Other<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_173_6'>\n\t\t\t\t<input name='input_173' type='radio' value='None'  id='choice_2_173_6'    \/>\n\t\t\t\t<label for='choice_2_173_6' id='label_2_173_6'>None<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Authorized to consent for this individual&#039;s health care?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_26'>\n\t\t\t<li class='gchoice gchoice_2_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_2_26_0'    \/>\n\t\t\t\t<label for='choice_2_26_0' id='label_2_26_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_2_26_1'    \/>\n\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_18' >Primary Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_2_18' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_168\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Who typically answers this phone?<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_168'>\n                            \n                            <span id='input_2_168_3_container' class='name_first' >\n                                                    <input type='text' name='input_168.3' id='input_2_168_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_168_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_168_6_container' class='name_last' >\n                                                    <input type='text' name='input_168.6' id='input_2_168_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_168_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_19' >Best Time to Call<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >OK to leave a message at this number?<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_2_27'>\n\t\t\t<li class='gchoice gchoice_2_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='Yes'  id='choice_2_27_0'    \/>\n\t\t\t\t<label for='choice_2_27_0' id='label_2_27_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_27_1'>\n\t\t\t\t<input name='input_27' type='radio' value='No'  id='choice_2_27_1'    \/>\n\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_21' >Second Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_2_21' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_169\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Who typically answers this phone?<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_169'>\n                            \n                            <span id='input_2_169_3_container' class='name_first' >\n                                                    <input type='text' name='input_169.3' id='input_2_169_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_169_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_169_6_container' class='name_last' >\n                                                    <input type='text' name='input_169.6' id='input_2_169_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_169_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_22\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_22' >Best Time to Call<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_28\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >OK to leave a message at this number?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_28'>\n\t\t\t<li class='gchoice gchoice_2_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_2_28_0'    \/>\n\t\t\t\t<label for='choice_2_28_0' id='label_2_28_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_2_28_1'    \/>\n\t\t\t\t<label for='choice_2_28_1' id='label_2_28_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_24' >Third Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_2_24' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_170\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Who typically answers this phone?<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_170'>\n                            \n                            <span id='input_2_170_3_container' class='name_first' >\n                                                    <input type='text' name='input_170.3' id='input_2_170_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_170_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_170_6_container' class='name_last' >\n                                                    <input type='text' name='input_170.6' id='input_2_170_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_170_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_25\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_25' >Best Time to Call<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_29\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >OK to leave a message at this number?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_29'>\n\t\t\t<li class='gchoice gchoice_2_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_2_29_0'    \/>\n\t\t\t\t<label for='choice_2_29_0' id='label_2_29_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_2_29_1'    \/>\n\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_100\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Is the person completing this form the one paying?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_100'>\n\t\t\t<li class='gchoice gchoice_2_100_0'>\n\t\t\t\t<input name='input_100' type='radio' value='Yes' checked='checked' id='choice_2_100_0'    \/>\n\t\t\t\t<label for='choice_2_100_0' id='label_2_100_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_100_1'>\n\t\t\t\t<input name='input_100' type='radio' value='No'  id='choice_2_100_1'    \/>\n\t\t\t\t<label for='choice_2_100_1' id='label_2_100_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_53\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h2 class=\"gsection_title\">Guarantor (the person paying)<\/h2><\/li><li id=\"field_2_54\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Guarantor Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_54'>\n                            \n                            <span id='input_2_54_3_container' class='name_first' >\n                                                    <input type='text' name='input_54.3' id='input_2_54_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_54_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_54_6_container' class='name_last' >\n                                                    <input type='text' name='input_54.6' id='input_2_54_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_54_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_55\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_55' >Guarantor Relationship to Client<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_56\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_56' >Guarantor Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_56' id='input_2_56' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_57\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Guarantor Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_2_57' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_57_1_container' >\n                                        <input type='text' name='input_57.1' id='input_2_57_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_57_1' id='input_2_57_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_2_57_2_container' >\n                                        <input type='text' name='input_57.2' id='input_2_57_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_57_2' id='input_2_57_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_57_3_container' >\n                                    <input type='text' name='input_57.3' id='input_2_57_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_57_3' id='input_2_57_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_57_4_container' >\n                                        <input type='text' name='input_57.4' id='input_2_57_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_57_4' id='input_2_57_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_57_5_container' >\n                                    <input type='text' name='input_57.5' id='input_2_57_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_57_5' id='input_2_57_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_57.6' id='input_2_57_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_105' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_105' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_30\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Insurance Information:  Primary Insurance Coverage<\/h2><\/li><li id=\"field_2_141\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_141' >Primary Insurance Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_141' id='input_2_141' class='medium gfield_select'  aria-describedby=\"gfield_description_2_141\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Aetna' >Aetna<\/option><option value='Anthem' >Anthem<\/option><option value='Benefit Administrative Systems' >Benefit Administrative Systems<\/option><option value='Blue Cross Blue Shield (BCBS)' >Blue Cross Blue Shield (BCBS)<\/option><option value='Champ VA' >Champ VA<\/option><option value='Cigna' >Cigna<\/option><option value='EBMS' >EBMS<\/option><option value='First Choice' >First Choice<\/option><option value='HMA' >HMA<\/option><option value='Kaiser' >Kaiser<\/option><option value='Lifewise' >Lifewise<\/option><option value='Meritain Health' >Meritain Health<\/option><option value='Pacific Source' >Pacific Source<\/option><option value='Premera' >Premera<\/option><option value='Regence' >Regence<\/option><option value='Tricare' >Tricare<\/option><option value='UMR' >UMR<\/option><option value='UnitedHealthcare (UHC)' >UnitedHealthcare (UHC)<\/option><option value='US Family Health Plan' >US Family Health Plan<\/option><option value='----------------------------------' >----------------------------------<\/option><option value='Community Health Plan of WA (CHPW)' >Community Health Plan of WA (CHPW)<\/option><option value='Coordinated Care of WA' >Coordinated Care of WA<\/option><option value='Molina Health Care of WA' >Molina Health Care of WA<\/option><option value='UnitedHealthcare Community Plan' >UnitedHealthcare Community Plan<\/option><option value='Wellpoint' >Wellpoint<\/option><option value='Other Medicaid Plan' >Other Medicaid Plan<\/option><option value='----------------------------------' >----------------------------------<\/option><option value='Medicare' >Medicare<\/option><option value='No insurance \/ self-pay' >No insurance \/ self-pay<\/option><option value='Other' >Other<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_141'>The first block of choices are COMMERCIAL Insurance companies. The second block is MEDICAID \/ WA APPLE CARE. The third block is OTHER. Please select from the appropriate section.<\/div><\/li><li id=\"field_2_142\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_142' >If you selected Other, please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_2_142' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_32\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_32' >Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_33\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_33' >Name of Benefit Plan<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_34\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Subscriber Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_34'>\n                            \n                            <span id='input_2_34_3_container' class='name_first' >\n                                                    <input type='text' name='input_34.3' id='input_2_34_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_2_34_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_34_6_container' class='name_last' >\n                                                    <input type='text' name='input_34.6' id='input_2_34_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_2_34_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_35\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Subscriber Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_2_35' class='ginput_container ginput_complex'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date' id='input_2_35_1_container'>\n                                            <input type='number'  name='input_35[]' id='input_2_35_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_35_1' class='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_2_35_2_container'>\n                                            <input type='number'  name='input_35[]' id='input_2_35_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_35_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_2_35_3_container'>\n                                            <input type='number'  name='input_35[]' id='input_2_35_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_2_35_3' class='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_2_88\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_88' >Subscriber SSN<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_2_88' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_37\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_37' >Patient Relationship to Subscriber (Self\/Dependent\/Spouse\/Other)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_38\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_38' >Subscriber ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_41' >Group Number (type &#039;None&#039; if not applicable)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_2_41' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_39\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_39' >Provider Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_39' id='input_2_39' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_40\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Insurance Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_2_40' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_40_1_container' >\n                                        <input type='text' name='input_40.1' id='input_2_40_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_40_1' id='input_2_40_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_2_40_2_container' >\n                                        <input type='text' name='input_40.2' id='input_2_40_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_40_2' id='input_2_40_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_40_3_container' >\n                                    <input type='text' name='input_40.3' id='input_2_40_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_40_3' id='input_2_40_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_40_4_container' >\n                                        <input type='text' name='input_40.4' id='input_2_40_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_40_4' id='input_2_40_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_40_5_container' >\n                                    <input type='text' name='input_40.5' id='input_2_40_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_40_5' id='input_2_40_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_40.6' id='input_2_40_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_106' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_106' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_42\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Insurance Information: Secondary Insurance Coverage<\/h2><\/li><li id=\"field_2_99\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Do you have a secondary insurer?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_99'>\n\t\t\t<li class='gchoice gchoice_2_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_2_99_0'    \/>\n\t\t\t\t<label for='choice_2_99_0' id='label_2_99_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No' checked='checked' id='choice_2_99_1'    \/>\n\t\t\t\t<label for='choice_2_99_1' id='label_2_99_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_144\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_144' >Secondary Insurance Company Name<\/label><div class='ginput_container ginput_container_select'><select name='input_144' id='input_2_144' class='medium gfield_select'  aria-describedby=\"gfield_description_2_144\"   aria-invalid=\"false\" ><option value='Aetna' >Aetna<\/option><option value='Anthem' >Anthem<\/option><option value='Benefit Administrative Systems' >Benefit Administrative Systems<\/option><option value='Blue Cross Blue Shield (BCBS)' >Blue Cross Blue Shield (BCBS)<\/option><option value='Champ VA' >Champ VA<\/option><option value='Cigna' >Cigna<\/option><option value='EBMS' >EBMS<\/option><option value='First Choice' >First Choice<\/option><option value='HMA' >HMA<\/option><option value='Kaiser' >Kaiser<\/option><option value='Lifewise' >Lifewise<\/option><option value='Meritain Health' >Meritain Health<\/option><option value='Pacific Source' >Pacific Source<\/option><option value='Premera' >Premera<\/option><option value='Regence' >Regence<\/option><option value='Tricare' >Tricare<\/option><option value='UMR' >UMR<\/option><option value='UnitedHealthcare (UHC)' >UnitedHealthcare (UHC)<\/option><option value='US Family Health Plan' >US Family Health Plan<\/option><option value='----------------------------------' >----------------------------------<\/option><option value='Community Health Plan of WA (CHPW)' >Community Health Plan of WA (CHPW)<\/option><option value='Coordinated Care of WA' >Coordinated Care of WA<\/option><option value='Molina Health Care of WA' >Molina Health Care of WA<\/option><option value='UnitedHealthcare Community Plan' >UnitedHealthcare Community Plan<\/option><option value='Wellpoint' >Wellpoint<\/option><option value='Other Medicaid Plan' >Other Medicaid Plan<\/option><option value='----------------------------------' >----------------------------------<\/option><option value='Medicare' >Medicare<\/option><option value='No insurance \/ self-pay' >No insurance \/ self-pay<\/option><option value='Other' >Other<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_144'>The first block of choices are COMMERCIAL Insurance companies. The second block is MEDICAID \/ WA APPLE CARE. The third block is OTHER. Please select from the appropriate section.<\/div><\/li><li id=\"field_2_145\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_145' >Please Specify Secondary Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_2_145' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_43\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_43' >Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_44\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_44' >Name of Benefit Plan<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_2_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_45\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Subscriber Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_45'>\n                            \n                            <span id='input_2_45_3_container' class='name_first' >\n                                                    <input type='text' name='input_45.3' id='input_2_45_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_45_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_45_6_container' class='name_last' >\n                                                    <input type='text' name='input_45.6' id='input_2_45_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_45_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Subscriber Date of Birth<\/label><div id='input_2_46' class='ginput_container ginput_complex'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date' id='input_2_46_1_container'>\n                                            <input type='number'  name='input_46[]' id='input_2_46_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_46_1' class='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_2_46_2_container'>\n                                            <input type='number'  name='input_46[]' id='input_2_46_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_46_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_2_46_3_container'>\n                                            <input type='number'  name='input_46[]' id='input_2_46_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_2_46_3' class='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_2_89\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_89' >Subscriber SSN<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_2_89' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_48\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_48' >Patient Relationship to Subscriber (Self\/Dependent\/Spouse\/Other)<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_49\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_49' >Subscriber ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_2_49' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_50\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_50' >Group Number<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_51\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_51' >Provider Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_51' id='input_2_51' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_52\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Insurance Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_2_52' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_52_1_container' >\n                                        <input type='text' name='input_52.1' id='input_2_52_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_52_1' id='input_2_52_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_2_52_2_container' >\n                                        <input type='text' name='input_52.2' id='input_2_52_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_52_2' id='input_2_52_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_52_3_container' >\n                                    <input type='text' name='input_52.3' id='input_2_52_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_52_3' id='input_2_52_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_52_4_container' >\n                                        <input type='text' name='input_52.4' id='input_2_52_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_52_4' id='input_2_52_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_52_5_container' >\n                                    <input type='text' name='input_52.5' id='input_2_52_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_52_5' id='input_2_52_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_52.6' id='input_2_52_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_58\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h2 class=\"gsection_title\">Legal Next of Kin<\/h2><\/li><li id=\"field_2_59\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_59'>\n                            \n                            <span id='input_2_59_3_container' class='name_first' >\n                                                    <input type='text' name='input_59.3' id='input_2_59_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_59_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_59_6_container' class='name_last' >\n                                                    <input type='text' name='input_59.6' id='input_2_59_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_59_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_60\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_60' >Next of Kin Relationship to Client<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_2_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_61\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_61' >Next of Kin Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_61' id='input_2_61' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_62\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h2 class=\"gsection_title\">Primary Healthcare Provider<\/h2><\/li><li id=\"field_2_67\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Primary Healthcare Provider Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_67'>\n                            \n                            <span id='input_2_67_3_container' class='name_first' >\n                                                    <input type='text' name='input_67.3' id='input_2_67_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_67_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_67_6_container' class='name_last' >\n                                                    <input type='text' name='input_67.6' id='input_2_67_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_67_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_64\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_64' >Clinic\/Hospital<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_2_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_65\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_65' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_65' id='input_2_65' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_66\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_2_66' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_66_1_container' >\n                                        <input type='text' name='input_66.1' id='input_2_66_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_66_1' id='input_2_66_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_2_66_2_container' >\n                                        <input type='text' name='input_66.2' id='input_2_66_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_66_2' id='input_2_66_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_66_3_container' >\n                                    <input type='text' name='input_66.3' id='input_2_66_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_66_3' id='input_2_66_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_66_4_container' >\n                                        <input type='text' name='input_66.4' id='input_2_66_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_66_4' id='input_2_66_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_66_5_container' >\n                                    <input type='text' name='input_66.5' id='input_2_66_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_66_5' id='input_2_66_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_66.6' id='input_2_66_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_109' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_109' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"6\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"6\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_6' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_6' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_68\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Household and Family Information<\/h2><\/li><li id=\"field_2_90\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Patient relationship status (select &quot;Single&quot; if client is child)<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_2_90'>\n\t\t\t<li class='gchoice gchoice_2_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Single'  id='choice_2_90_0'    \/>\n\t\t\t\t<label for='choice_2_90_0' id='label_2_90_0'>Single<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='Married'  id='choice_2_90_1'    \/>\n\t\t\t\t<label for='choice_2_90_1' id='label_2_90_1'>Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_90_2'>\n\t\t\t\t<input name='input_90' type='radio' value='Divorced'  id='choice_2_90_2'    \/>\n\t\t\t\t<label for='choice_2_90_2' id='label_2_90_2'>Divorced<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_90_3'>\n\t\t\t\t<input name='input_90' type='radio' value='Separated'  id='choice_2_90_3'    \/>\n\t\t\t\t<label for='choice_2_90_3' id='label_2_90_3'>Separated<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_90_4'>\n\t\t\t\t<input name='input_90' type='radio' value='Other'  id='choice_2_90_4'    \/>\n\t\t\t\t<label for='choice_2_90_4' id='label_2_90_4'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_87\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >If living with parents, indicate relationship status of parents<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_87'>\n\t\t\t<li class='gchoice gchoice_2_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Single'  id='choice_2_87_0'    \/>\n\t\t\t\t<label for='choice_2_87_0' id='label_2_87_0'>Single<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Married'  id='choice_2_87_1'    \/>\n\t\t\t\t<label for='choice_2_87_1' id='label_2_87_1'>Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='Divorced'  id='choice_2_87_2'    \/>\n\t\t\t\t<label for='choice_2_87_2' id='label_2_87_2'>Divorced<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_87_3'>\n\t\t\t\t<input name='input_87' type='radio' value='Separated'  id='choice_2_87_3'    \/>\n\t\t\t\t<label for='choice_2_87_3' id='label_2_87_3'>Separated<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_87_4'>\n\t\t\t\t<input name='input_87' type='radio' value='Other'  id='choice_2_87_4'    \/>\n\t\t\t\t<label for='choice_2_87_4' id='label_2_87_4'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_71\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_71' >If parents are divorced or separated, please indicate the type of custody (joint\/sole)<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_2_71' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_72\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gfield_label_before_complex'  >Custody Holder Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_72'>\n                            \n                            <span id='input_2_72_3_container' class='name_first' >\n                                                    <input type='text' name='input_72.3' id='input_2_72_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_2_72_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_72_6_container' class='name_last' >\n                                                    <input type='text' name='input_72.6' id='input_2_72_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_2_72_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_73\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_73' >Who is responsible for medical decisions regarding the client?  (If client is adult, please specify any guardianship or power-of-attorney.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_74\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_74' >Primary language spoken in home<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_2_74' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_75\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_75' >Other languages spoken<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_2_75' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_166\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Do you or your child need an interpreter for your appointments?<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_2_166'>\n\t\t\t<li class='gchoice gchoice_2_166_0'>\n\t\t\t\t<input name='input_166' type='radio' value='Yes'  id='choice_2_166_0'    \/>\n\t\t\t\t<label for='choice_2_166_0' id='label_2_166_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_166_1'>\n\t\t\t\t<input name='input_166' type='radio' value='No'  id='choice_2_166_1'    \/>\n\t\t\t\t<label for='choice_2_166_1' id='label_2_166_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_110' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_110' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"7\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"7\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_7' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_7' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_76\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Services Being Pursued<\/h2><\/li><li id=\"field_2_80\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Has the patient been diagnosed with Autism?<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_2_80'>\n\t\t\t<li class='gchoice gchoice_2_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_2_80_0'    \/>\n\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='No'  id='choice_2_80_1'    \/>\n\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_81\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_81' >When and by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_2_81' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_178\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>\nIf your child has already received an autism evaluation, please let us know.\u202f\u202f\u202f\u00a0\nDue to the number of children still awaiting an initial evaluation, the UW Autism Center only completes re-evaluations in exceptional circumstances and with the pre-approval of our Director of Clinical Services.\u00a0\n<\/p>\n<p>\nIf you have an appointment with another provider for an autism evaluation prior to your initial appointment with UWAC, you must let us know as soon as possible. We will not be able to proceed without pre-approval for a re-evaluation.\u00a0\n<\/p><\/li><li id=\"field_2_92\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_92' >Please indicate which services(s) you are interested in pursuing at the UW Autism Center. (NOTE:  Currently our Tacoma branch is not offering ABA services, and neither site is accepting requests for adult (18+) diagnostic evaluations at this time.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_92[]' id='input_2_92' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='Diagnostic Evaluation (Offered in Seattle)' >Diagnostic Evaluation (Offered in Seattle)<\/option><option value='ABA Services' >ABA Services<\/option><option value='Speech &amp; Language (Offered in Seattle)' >Speech &amp; Language (Offered in Seattle)<\/option><option value='Behavioral Sleep Clinic (Offered in Seattle)' >Behavioral Sleep Clinic (Offered in Seattle)<\/option><option value='Feeding &amp; Mealtime Clinic (Offered in Seattle)' >Feeding &amp; Mealtime Clinic (Offered in Seattle)<\/option><option value='Augmentative and Alternative Communication (AAC) Clinic (Offered in Seattle)' >Augmentative and Alternative Communication (AAC) Clinic (Offered in Seattle)<\/option><option value='Hanen Parent Programs (Offered in Seattle)' >Hanen Parent Programs (Offered in Seattle)<\/option><option value='Occupational Therapy (Offered in Seattle)' >Occupational Therapy (Offered in Seattle)<\/option><option value='Collaborative Problem Solving via Zoom (Offered in Seattle)' >Collaborative Problem Solving via Zoom (Offered in Seattle)<\/option><option value='LAUNCH (Medicaid 12-week ABA program) (Offered in Seattle)' >LAUNCH (Medicaid 12-week ABA program) (Offered in Seattle)<\/option><option value='Diagnostic Evaluation (Offered in Tacoma)' >Diagnostic Evaluation (Offered in Tacoma)<\/option><option value='LAUNCH (Medicaid 12-week ABA program) (Offered in Tacoma)' >LAUNCH (Medicaid 12-week ABA program) (Offered in Tacoma)<\/option><option value='Collaborative Problem Solving via Zoom (Offered in Tacoma)' >Collaborative Problem Solving via Zoom (Offered in Tacoma)<\/option><option value='Other (note in comments)' >Other (note in comments)<\/option><\/select><\/div><\/li><li id=\"field_2_95\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Desired Site of Service<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_2_95'>\n\t\t\t<li class='gchoice gchoice_2_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Seattle'  id='choice_2_95_0'    \/>\n\t\t\t\t<label for='choice_2_95_0' id='label_2_95_0'>Seattle<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='Tacoma'  id='choice_2_95_1'    \/>\n\t\t\t\t<label for='choice_2_95_1' id='label_2_95_1'>Tacoma<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_95_2'>\n\t\t\t\t<input name='input_95' type='radio' value='Either'  id='choice_2_95_2'    \/>\n\t\t\t\t<label for='choice_2_95_2' id='label_2_95_2'>Either<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_126\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Has this client been seen at UWAC before?<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_2_126'>\n\t\t\t<li class='gchoice gchoice_2_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_2_126_0'    \/>\n\t\t\t\t<label for='choice_2_126_0' id='label_2_126_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_2_126_1'    \/>\n\t\t\t\t<label for='choice_2_126_1' id='label_2_126_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_127\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_127' >Approximately when was the client seen at UWAC, and for which services?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_2_127' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_135\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Has patient been evaluated by a 0-3 program?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_135'>\n\t\t\t<li class='gchoice gchoice_2_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='Yes'  id='choice_2_135_0'    \/>\n\t\t\t\t<label for='choice_2_135_0' id='label_2_135_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='No'  id='choice_2_135_1'    \/>\n\t\t\t\t<label for='choice_2_135_1' id='label_2_135_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_136\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_136' >If so, where and approximately when?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_136' id='input_2_136' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_137\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Are there speech &amp; language concerns about the patient?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_137'>\n\t\t\t<li class='gchoice gchoice_2_137_0'>\n\t\t\t\t<input name='input_137' type='radio' value='Yes'  id='choice_2_137_0'    \/>\n\t\t\t\t<label for='choice_2_137_0' id='label_2_137_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_137_1'>\n\t\t\t\t<input name='input_137' type='radio' value='No'  id='choice_2_137_1'    \/>\n\t\t\t\t<label for='choice_2_137_1' id='label_2_137_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_140\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Is the patient seeing an SLP?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_140'>\n\t\t\t<li class='gchoice gchoice_2_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Yes'  id='choice_2_140_0'    \/>\n\t\t\t\t<label for='choice_2_140_0' id='label_2_140_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_2_140_1'    \/>\n\t\t\t\t<label for='choice_2_140_1' id='label_2_140_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_138\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_138' >If so, what goals are they working on?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_138' id='input_2_138' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_111' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"6\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"6\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_111' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"8\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"8\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_8' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_8' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_78\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Additional Questions and Comments<\/h2><\/li><li id=\"field_2_79\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_79' >Who referred you for services?<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_2_79' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_174\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Referral Category<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_174'>\n\t\t\t<li class='gchoice gchoice_2_174_0'>\n\t\t\t\t<input name='input_174' type='radio' value='Primary Care Provider'  id='choice_2_174_0'    \/>\n\t\t\t\t<label for='choice_2_174_0' id='label_2_174_0'>Primary Care Provider<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_1'>\n\t\t\t\t<input name='input_174' type='radio' value='Self &amp; Family'  id='choice_2_174_1'    \/>\n\t\t\t\t<label for='choice_2_174_1' id='label_2_174_1'>Self & Family<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_2'>\n\t\t\t\t<input name='input_174' type='radio' value='Hospital'  id='choice_2_174_2'    \/>\n\t\t\t\t<label for='choice_2_174_2' id='label_2_174_2'>Hospital<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_3'>\n\t\t\t\t<input name='input_174' type='radio' value='Physician Specialist'  id='choice_2_174_3'    \/>\n\t\t\t\t<label for='choice_2_174_3' id='label_2_174_3'>Physician Specialist<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_4'>\n\t\t\t\t<input name='input_174' type='radio' value='Public Health Agency'  id='choice_2_174_4'    \/>\n\t\t\t\t<label for='choice_2_174_4' id='label_2_174_4'>Public Health Agency<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_5'>\n\t\t\t\t<input name='input_174' type='radio' value='School'  id='choice_2_174_5'    \/>\n\t\t\t\t<label for='choice_2_174_5' id='label_2_174_5'>School<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_6'>\n\t\t\t\t<input name='input_174' type='radio' value='Other Health Professional'  id='choice_2_174_6'    \/>\n\t\t\t\t<label for='choice_2_174_6' id='label_2_174_6'>Other Health Professional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_7'>\n\t\t\t\t<input name='input_174' type='radio' value='Other\/Unknown\/None'  id='choice_2_174_7'    \/>\n\t\t\t\t<label for='choice_2_174_7' id='label_2_174_7'>Other\/Unknown\/None<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_102\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_102' >What are some of your or the referral source&#039;s concerns regarding the client?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_102' id='input_2_102' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_128\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_128' >What is the client&#039;s school schedule, if any?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_2_128' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_129\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_129' >What days\/times generally work best for you?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_2_129' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_97\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >If you have a flexible schedule and can easily come to the center at the last minute, we can put you on a list to be called in the event of a cancelation. Would you like to be put on this list?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_97'>\n\t\t\t<li class='gchoice gchoice_2_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Yes'  id='choice_2_97_0'    \/>\n\t\t\t\t<label for='choice_2_97_0' id='label_2_97_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='No' checked='checked' id='choice_2_97_1'    \/>\n\t\t\t\t<label for='choice_2_97_1' id='label_2_97_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_98\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_2_98' >If you have standing times and\/or days of the week that you know you will NOT be able to come, please specify them here:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_98' id='input_2_98' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_82\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_82' >Additional Comments (optional)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_2_82' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_112' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"7\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"7\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_112' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"9\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"9\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_9' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_9' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_83\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Client Communication Agreement<\/h2><\/li><li id=\"field_2_132\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >May we contact you in the future to:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_132'><li class='gchoice gchoice_2_132_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.1' type='checkbox'  value='Inform you of research study opportunities?'  id='choice_2_132_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_132_1' id='label_2_132_1'>Inform you of research study opportunities?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_132_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.2' type='checkbox'  value='Invite you to events (e.g. Open Houses, Benefit Dinners)?'  id='choice_2_132_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_132_2' id='label_2_132_2'>Invite you to events (e.g. Open Houses, Benefit Dinners)?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_132_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.3' type='checkbox'  value='Send you our Newsletter?'  id='choice_2_132_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_132_3' id='label_2_132_3'>Send you our Newsletter?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_84\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >The UW Autism Center would like your permission to communicate with you regarding your services via email. Is this ok?<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_2_84'>\n\t\t\t<li class='gchoice gchoice_2_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Yes' checked='checked' id='choice_2_84_0'    \/>\n\t\t\t\t<label for='choice_2_84_0' id='label_2_84_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='No'  id='choice_2_84_1'    \/>\n\t\t\t\t<label for='choice_2_84_1' id='label_2_84_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_85\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_2_85' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_85' id='input_2_85' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_86\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>If no, please indicate in the Additional Comments above how best to contact you (please note, this phone number will be filed as the best way to reach you in case of emergency).<\/p><p><b>Individual Providers and clients may decide to use email to facilitate communication. Some Providers at UW Autism Center may communicate via email, but this agreement does not obligate all UW Autism Center Providers to communicate via email. Email may be one of many forms of communication with UW Autism Center.  I want to use email to communicate to UW Autism Center Providers and staff about my\/the client\u2019s personal health care. I understand that UW Autism Center Providers and staff will use reasonable means to protect the security and confidentiality of email information sent and received. I understand that there are known and unknown risks that may affect the privacy of my personal health care information when using email to communicate. I acknowledge that those risks include, but are not limited, to: * Email can be forwarded, printed, and stored in numerous paper and electronic forms and be received by many intended and unintended recipients without my knowledge or agreement. * Email may be sent to the wrong address by any sender or receiver. * Email is easier to forge than handwritten or signed papers. * Copies of email may exist even after the sender or the receiver has deleted his or her copy. * Email service providers have a right to archive and inspect emails sent through their systems. * Email can be intercepted, altered, forwarded, or used without detection or authorization. * Email can spread computer viruses. * Email delivery is not guaranteed. Conditions for the use of email I agree that I must not use email for medical emergencies or to send time sensitive information to my\/the client\u2019s Providers. I understand and agree that it is my responsibility to follow up with UW Autism Center Providers or staff, if I have not received a response to my email within a reasonable time period. I agree that the content of my email messages should state my question or concern briefly and clearly and include (1) the subject of the message in the subject line, and (2) clear identification including client\u2019s name, parent\u2019s name, and telephone number in the body of the message. I agree it is my responsibility to inform UW Autism Center of any changes to my email address. I agree that, if I want to withdraw my consent to use email communications about my\/the client\u2019s healthcare, it is my responsibility to inform my\/the client\u2019s Providers or staff member only by email or written communication Understanding the use of email I give permission to UW Autism Center Providers and staff to send me email messages that include my\/the client\u2019s personal health care information and understand that my email messages may be included in my\/the patient\u2019s medical record. I have read and understand the risks of using email as stated above and agree that email messages may include protected health information about me\/the client, whenever necessary .<\/p><p>\n\nBY CLICKING SUBMIT YOU APPROVE HAVING THIS FILE SENT ELECTRONICALLY TO THE UW AUTISM CENTER<\/p><\/b><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsImFhY2MxMjc4MmFjNTNiZTlhYTJhNTNjOWZjNTRlYjA0Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":2602,"parent":15,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-2976","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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