{"id":1198,"date":"2019-01-31T23:32:39","date_gmt":"2019-01-31T23:32:39","guid":{"rendered":"https:\/\/brainchanger.io\/?page_id=1198"},"modified":"2019-01-31T23:32:39","modified_gmt":"2019-01-31T23:32:39","slug":"practitioners-contact-form","status":"publish","type":"page","link":"https:\/\/brainchanger.io\/practitioners-contact-form\/","title":{"rendered":"Practitioners Contact Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1197\"><form id=\"wpforms-form-1197\" class=\"wpforms-validate wpforms-form\" data-formid=\"1197\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/1198\/\" data-token=\"58f95856b3b6334607bb30acc7de3cdb\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1197-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_1\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1197-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-1197-field_1\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1197-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-1197-field_1-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1197-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_2\">Professional Qualification<\/label><input type=\"text\" id=\"wpforms-1197-field_2\" class=\"wpforms-field-large\" name=\"wpforms[fields][2]\" ><\/div><div id=\"wpforms-1197-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_3\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1197-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1197-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_4\">Name of Clinic\/Organisation <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1197-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-1197-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_6\">Address Line 1 <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1197-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-1197-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_7\">Address Line 2<\/label><input type=\"text\" id=\"wpforms-1197-field_7\" class=\"wpforms-field-large\" name=\"wpforms[fields][7]\" ><\/div><div id=\"wpforms-1197-field_8-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_8\">City <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1197-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-1197-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_9\">State <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1197-field_9\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-1197-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_10\">Postcode <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1197-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-1197-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_13\">Country <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1197-field_13\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][13]\" required><\/div><div id=\"wpforms-1197-field_11-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_11\">Tell me what you\u2019re looking for:<\/label><ul id=\"wpforms-1197-field_11\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1197-field_11_1\" name=\"wpforms[fields][11][]\" value=\"Tool to help clients better self-manage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1197-field_11_1\">Tool to help clients better self-manage<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1197-field_11_2\" name=\"wpforms[fields][11][]\" value=\"Tool to help reduce reliance on medication\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1197-field_11_2\">Tool to help reduce reliance on medication<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1197-field_11_3\" name=\"wpforms[fields][11][]\" value=\"Curriculum for delivering pain education\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1197-field_11_3\">Curriculum for delivering pain education<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1197-field_11_5\" name=\"wpforms[fields][11][]\" value=\"Research opportunity\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1197-field_11_5\">Research opportunity<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1197-field_11_4\" name=\"wpforms[fields][11][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1197-field_11_4\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1197-field_12-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_12\">If Other, provide details:<\/label><textarea id=\"wpforms-1197-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\" ><\/textarea><\/div><div id=\"wpforms-1197-field_14-container\" class=\"wpforms-field wpforms-field-captcha\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1197-field_14\">Please answer the following math question (captcha) <span class=\"wpforms-required-label\">*<\/span><\/label><p id=\"wpforms-1197-field_14-question\" class=\"wpforms-captcha-question\">What is 7+4?<\/p>\n\t\t\t<input type=\"text\" id=\"wpforms-1197-field_14\" class=\"wpforms-field-medium wpforms-field-required a\" data-rule-wpf-captcha=\"qa\" data-is-wrapped-field=\"1\" data-a=\"11\" name=\"wpforms[fields][14][a]\" aria-describedby=\"wpforms-1197-field_14-question\" required>\n\t\t\t<input type=\"hidden\" name=\"wpforms[fields][14][q]\" value=\"1\">\n\n\t\t\t<\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-1197-field-hp\" class=\"wpforms-field-label\">Comment<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-1197-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1197\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1197\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/1198"}],"collection":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/comments?post=1198"}],"version-history":[{"count":1,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/1198\/revisions"}],"predecessor-version":[{"id":1199,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/1198\/revisions\/1199"}],"wp:attachment":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/media?parent=1198"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}