{"id":2268,"date":"2018-01-14T11:07:01","date_gmt":"2018-01-14T11:07:01","guid":{"rendered":"http:\/\/wp.bwlthemes.com\/wp_srcare\/?page_id=2268"},"modified":"2023-10-19T16:25:37","modified_gmt":"2023-10-19T16:25:37","slug":"appointment-form","status":"publish","type":"page","link":"https:\/\/highcareaustralia.com\/?page_id=2268","title":{"rendered":"Referral Form"},"content":{"rendered":"<section class=\"wpb-content-wrapper\">[vc_row disable_element=&#8221;yes&#8221; srcare_custom_class=&#8221;section-content-block&#8221; css=&#8221;.vc_custom_1697732231075{padding-bottom: 0px !important;background-image: url(http:\/\/wp.bwlthemes.com\/wp_srcare\/wp-content\/uploads\/2018\/01\/appointment_bg.jpg?id=2273) !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;}&#8221; el_class=&#8221;appointment-form-row&#8221;][vc_column width=&#8221;1\/2&#8243; css=&#8221;.vc_custom_1515929240196{margin-top: 0px !important;margin-right: 0px !important;margin-bottom: 0px !important;margin-left: 0px !important;border-top-width: 0px !important;border-right-width: 0px !important;border-bottom-width: 0px !important;border-left-width: 0px !important;padding-top: 0px !important;padding-right: 0px !important;padding-bottom: 0px !important;padding-left: 0px !important;background-position: 0 0 !important;background-repeat: no-repeat !important;}&#8221; el_class=&#8221;section-heading-wrapper section-heading-wrapper-alt inline-heading-style&#8221; offset=&#8221;vc_col-lg-offset-0 vc_col-lg-6 vc_col-md-offset-0 vc_col-md-6 vc_hidden-md vc_col-sm-offset-0 vc_hidden-sm vc_hidden-xs&#8221;][vc_column_text]\n<h2 class=\"margin-top-90\"><strong class=\"text-curly text-curly-no-italic text-primary-color\">Ready To Join?<\/strong><br \/>\nComplete family environment<br \/>\nAlways available in here !<\/h2>\n<p>We are ensuring joyful and clam living environment for our elders.[\/vc_column_text][vc_single_image image=&#8221;2277&#8243; img_size=&#8221;full&#8221; css_animation=&#8221;slideInLeft&#8221; el_class=&#8221;pull-right&#8221;][\/vc_column][vc_column width=&#8221;1\/2&#8243; offset=&#8221;vc_col-lg-offset-0 vc_col-lg-6 vc_col-md-offset-0 vc_col-md-12 vc_col-sm-offset-0 vc_col-xs-12&#8243;][vc_column_text]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2267-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2268#wpcf7-f2267-o1\" method=\"post\" class=\"wpcf7-form init srcare-appointment-form\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2267\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8.1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2267-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"appointment-form-wrapper text-center clearfix\">\n\t<div class=\"row\">\n\t\t<div class=\"col-md-12\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"NAME\" value=\"\" type=\"text\" name=\"customer_name\" \/><\/span><span class=\"fa fa-user-o\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"EMAIL\" value=\"\" type=\"email\" name=\"customer_email\" \/><\/span><i class=\"fa fa-envelope-o\"><\/i>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-12\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"PHONE\" value=\"\" type=\"text\" name=\"customer_phone\" \/><\/span><i class=\"fa fa-phone\"><\/i>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-12\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_message\"><textarea cols=\"40\" rows=\"4\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"YOUR MESSAGE\" name=\"customer_message\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner btn-theme\" type=\"submit\" value=\"Book An Appointment\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2679-o2\" lang=\"en-AU\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2268#wpcf7-f2679-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2679\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8.1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_AU\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2679-o2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"appointment-form-wrapper text-center clearfix\">\n\t<div class=\"row\">\n\t\t<h3>Participant Details\n\t\t<\/h3>\n\t<hr \/>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"NDIS No.\" value=\"\" type=\"text\" name=\"customer_name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"PlanStartDate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" placeholder=\"Plan Start Date\" value=\"\" type=\"date\" name=\"PlanStartDate\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"PlanEndDate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" placeholder=\"Plan End Date\" value=\"\" type=\"date\" name=\"PlanEndDate\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"FIRST NAME\" value=\"\" type=\"text\" name=\"customer_name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"customer_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"LAST NAME\" value=\"\" type=\"text\" name=\"customer_name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"gender\"><option value=\"MALE\">MALE<\/option><option value=\"FEMALE\">FEMALE<\/option><option value=\"OTHER\">OTHER<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" placeholder=\"Date Of Birth\" value=\"\" type=\"date\" name=\"DOB\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"MOBILE\/PHONE\" value=\"\" type=\"text\" name=\"mobile\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"Address\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email-513\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"EMAIL\" value=\"\" type=\"email\" name=\"email-513\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"FormalDiagnosis\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Formal Diagnosis\" value=\"\" type=\"text\" name=\"FormalDiagnosis\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"InterpreterRequiredYN\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Interpreter Required?(Y\/N)\" value=\"\" type=\"text\" name=\"InterpreterRequiredYN\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h3>Referrer Details\n\t<\/h3>\n<hr \/>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referral_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"referral_name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Organization\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Organization\" value=\"\" type=\"text\" name=\"Organization\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relationship\" value=\"\" type=\"text\" name=\"Relationship\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referralemail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referral Email\" value=\"\" type=\"email\" name=\"referralemail\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"contact\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-4\">\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div align=\"left\" class=\"col-md-12\">\n\t\t\t\t<h4>Payment\n\t\t\t\t<\/h4>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"PaymentMethod\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"PaymentMethod\" value=\"Agency Managed\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Agency Managed<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"PaymentMethod\" value=\"Plan Managed\" \/><span class=\"wpcf7-list-item-label\">Plan Managed<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"PaymentMethod\" value=\"Self Managed\" \/><span class=\"wpcf7-list-item-label\">Self Managed<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div align=\"left\" class=\"row\">\n\t\t\t<p>If Plan Managed or Self Managed, Please provide details\n\t\t\t<\/p>\n\t\t\t<div class=\"col-md-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"fname\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"col-md-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"lname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"lname\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"col-md-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invoicingemail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Invoicing Email\" value=\"\" type=\"email\" name=\"invoicingemail\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-md-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"NameofOrganization\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name of Organization\" value=\"\" type=\"text\" name=\"NameofOrganization\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<h3>Services Required\n\t\t<\/h3>\n\t<hr \/>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-md-4\">\n\t\t\t\t<p>Check if Psychology needed\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Psychology\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"Psychology[]\" value=\"Psychology\" \/><span class=\"wpcf7-list-item-label\">Psychology<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"col-md-4\">\n\t\t\t\t<p>Check if Occupational Therapy needed\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"OccupationalTherapy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"OccupationalTherapy[]\" value=\"Occupational Therapy\" \/><span class=\"wpcf7-list-item-label\">Occupational Therapy<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"col-md-4\">\n\t\t\t\t<p>Preferred mode of service delivery\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"preferredmode\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"preferredmode\" value=\"Face-to-face\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Face-to-face<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"preferredmode\" value=\"Telehealth\" \/><span class=\"wpcf7-list-item-label\">Telehealth<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div align=\"left\" class=\"col-md-9\">\n\t\t\t\t<p>Reason for Referral (Required if psychology\/OT needed)\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"answer\"><textarea cols=\"40\" rows=\"3\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Add answer here\" name=\"answer\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div align=\"left\" class=\"col-md-6\">\n\t\t\t\t<p>Core Service Required\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"servicerequired\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"servicerequired[]\" value=\"Domestic care\" \/><span class=\"wpcf7-list-item-label\">Domestic care<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"servicerequired[]\" value=\"Social &amp; Community Participation\" \/><span class=\"wpcf7-list-item-label\">Social &amp; Community Participation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"servicerequired[]\" value=\"In-Home Nursing\" \/><span class=\"wpcf7-list-item-label\">In-Home Nursing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"servicerequired[]\" value=\"Companionship\" \/><span class=\"wpcf7-list-item-label\">Companionship<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"servicerequired[]\" value=\"Support Coordination\" \/><span class=\"wpcf7-list-item-label\">Support Coordination<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"servicerequired[]\" value=\"Respite Care\" \/><span class=\"wpcf7-list-item-label\">Respite Care<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div align=\"left\" class=\"col-md-6\">\n\t\t\t\t<p>Preferred days for requested supports\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"days\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"days[]\" value=\"Sunday\" \/><span class=\"wpcf7-list-item-label\">Sunday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"days[]\" value=\"Monday\" \/><span class=\"wpcf7-list-item-label\">Monday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"days[]\" value=\"Wednesday\" \/><span class=\"wpcf7-list-item-label\">Wednesday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"days[]\" value=\"Thursday\" \/><span class=\"wpcf7-list-item-label\">Thursday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"days[]\" value=\"Friday\" \/><span class=\"wpcf7-list-item-label\">Friday<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"days[]\" value=\"Saturday\" \/><span class=\"wpcf7-list-item-label\">Saturday<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div align=\"left\" class=\"col-md-12\">\n\t\t\t\t<p>Attach ndis plan\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"file-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx\" aria-invalid=\"false\" type=\"file\" name=\"file-3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Form\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row]\n<\/section>","protected":false},"excerpt":{"rendered":"<p>[vc_row disable_element=&#8221;yes&#8221; srcare_custom_class=&#8221;section-content-block&#8221; css=&#8221;.vc_custom_1697732231075{padding-bottom: 0px !important;background-image: url(http:\/\/wp.bwlthemes.com\/wp_srcare\/wp-content\/uploads\/2018\/01\/appointment_bg.jpg?id=2273) !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;}&#8221; 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[&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-fullwidth.php","meta":{"footnotes":""},"class_list":["post-2268","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=\/wp\/v2\/pages\/2268","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2268"}],"version-history":[{"count":3,"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=\/wp\/v2\/pages\/2268\/revisions"}],"predecessor-version":[{"id":2682,"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=\/wp\/v2\/pages\/2268\/revisions\/2682"}],"wp:attachment":[{"href":"https:\/\/highcareaustralia.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2268"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}