{"id":8396,"date":"2019-11-27T04:26:08","date_gmt":"2019-11-27T04:26:08","guid":{"rendered":"http:\/\/brainchanger.io\/?page_id=8396"},"modified":"2023-01-17T01:19:00","modified_gmt":"2023-01-17T01:19:00","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/brainchanger.io\/refer-a-patient\/","title":{"rendered":"Refer A Patient"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"8396\" class=\"elementor elementor-8396\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7c0c5e84 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7c0c5e84\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-55cf3007\" data-id=\"55cf3007\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-475e4614 elementor-widget elementor-widget-shortcode\" data-id=\"475e4614\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:25px;padding-right:25px;padding-bottom:0px;padding-left:25px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#000000;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\"><div><img decoding=\"async\" src=\"http:\/\/brainchanger.io\/wp-content\/uploads\/2022\/02\/BR-Logo-FullColour-Rectangle.png\" height=\"auto\" width=\"250px\" style=\"padding-bottom:40px;\"><\/div>\n<p><b style=\"font-size: 34px; line-height: 54px; color: #000000;\" data-fusion-font=\"true\">BOOST Recovery Program - Referral Form<\/b><\/p>\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-8392\"><form id=\"wpforms-form-8392\" class=\"wpforms-validate wpforms-form\" data-formid=\"8392\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/8396\/?wpforms_form_id=8392\" data-token=\"9db6a07d9cf3baa38b71dee168bdc405\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-8392-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_6\">Patient Full Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><div class=\"wpforms-field-description\">First name, last name<\/div><\/div><div id=\"wpforms-8392-field_14-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_14\">Patient Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-8392-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-8392-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_23\">Patient Mobile Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-8392-field_38-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_38\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-8392-field_38\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][38][address1]\" required><label for=\"wpforms-8392-field_38\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-8392-field_38-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][38][address2]\" ><label for=\"wpforms-8392-field_38-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-8392-field_38-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][38][city]\" required><label for=\"wpforms-8392-field_38-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-8392-field_38-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][38][state]\" required><label for=\"wpforms-8392-field_38-state\" class=\"wpforms-field-sublabel after \">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-8392-field_38-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][38][postal]\" required><label for=\"wpforms-8392-field_38-postal\" class=\"wpforms-field-sublabel after \">Postal Code<\/label><\/div><\/div><\/div><div id=\"wpforms-8392-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_32\">This person typically responds to:<\/label><ul id=\"wpforms-8392-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8392-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Phone calls\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_32_1\">Phone calls<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8392-field_32_2\" name=\"wpforms[fields][32][]\" value=\"Voice mail\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_32_2\">Voice mail<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8392-field_32_3\" name=\"wpforms[fields][32][]\" value=\"Text message\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_32_3\">Text message<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-8392-field_32_4\" name=\"wpforms[fields][32][]\" value=\"Email\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_32_4\">Email<\/label><\/li><\/ul><\/div><div id=\"wpforms-8392-field_37-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_37\">Is this claim early intervention (up to 12 weeks post-injury)?<\/label><ul id=\"wpforms-8392-field_37\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8392-field_37_1\" name=\"wpforms[fields][37][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_37_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8392-field_37_2\" name=\"wpforms[fields][37][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_37_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-8392-field_30-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_30\">This referral is covered by:<\/label><ul id=\"wpforms-8392-field_30\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-8392-field_30_1\" name=\"wpforms[fields][30]\" value=\"Work Cover\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_30_1\">Work Cover<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-8392-field_30_2\" name=\"wpforms[fields][30]\" value=\"CTP\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8392-field_30_2\">CTP<\/label><\/li><\/ul><\/div><div id=\"wpforms-8392-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_9\">Claim number if Work Cover\/CTP <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-8392-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_24\">If Work Cover or CTP, please provide a summary of the claim <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-8392-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/textarea><\/div><div id=\"wpforms-8392-field_41-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_41\">Client Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-8392-field_41\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][41][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-8392-field_42-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_42\">Date of Injury <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-8392-field_42\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][42][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-8392-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_39\">How many hours per week client currently certified for? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_39\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" required><\/div><div id=\"wpforms-8392-field_31-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_31\">Upload case notes (20MB max).<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"31\"\n\t\tdata-form-id=\"8392\"\n\t\tdata-input-name=\"wpforms_8392_31\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,png,gif,mov,qt,avi,mpeg,mpg,mpe,3gp,3gpp,3g2,3gp2,mid,midi,pdf,doc,docx,docm,pot,pps,ppt,pptx,pptm,odt,ppsx,ppsm,xla,xls,xlt,xlw,xlsx,xlsm,xlsb,key,mp3,m4a,m4b,ogg,oga,flac,wav,mp4,m4v,webm,ogv,json\"\n\t\tdata-max-size=\"16777216\"\n\t\tdata-max-file-number=\"20\"\n\t\tdata-post-max-size=\"16777216\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 20 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-8392-field_31\"\n\t\tname=\"wpforms_8392_31\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-8392-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_33\">Referrer Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_33\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][33]\" required><\/div><div id=\"wpforms-8392-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_34\">Referrer Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" required><\/div><div id=\"wpforms-8392-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_35\">Referrer Relationship<\/label><input type=\"text\" id=\"wpforms-8392-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-8392-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_10\">Case Manager name (write &#039;As Above&#039; if same as referrer) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-8392-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_4\">Case Manager Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-8392-field_36-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_36\">Case Manager Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-8392-field_36\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][36]\" required><\/div><div id=\"wpforms-8392-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_43\">IMA\/HWA Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8392-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" required><\/div><div id=\"wpforms-8392-field_45-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_45\">IMA\/HWA Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-8392-field_45\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][45]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-8392-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-8392-field_28\">Message <\/label><textarea id=\"wpforms-8392-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-8392-field-hp\" class=\"wpforms-field-label\">Comment<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-8392-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"8392\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-8392\" 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<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","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\/8396"}],"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=8396"}],"version-history":[{"count":10,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/8396\/revisions"}],"predecessor-version":[{"id":18976,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/8396\/revisions\/18976"}],"wp:attachment":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/media?parent=8396"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}