{"id":914,"date":"2023-11-08T02:47:51","date_gmt":"2023-11-08T02:47:51","guid":{"rendered":"https:\/\/newheightspediatrictherapy.com\/?page_id=914"},"modified":"2024-02-06T16:48:27","modified_gmt":"2024-02-06T16:48:27","slug":"contact-info-form","status":"publish","type":"page","link":"https:\/\/newheightspediatrictherapy.com\/index.php\/contact-info-form\/","title":{"rendered":"Contact Info Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"914\" class=\"elementor elementor-914\">\n\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-628351b e-flex e-con-boxed e-con e-parent\" data-id=\"628351b\" data-element_type=\"container\" data-settings=\"{&quot;content_width&quot;:&quot;boxed&quot;}\" data-core-v316-plus=\"true\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b16c562 elementor-widget elementor-widget-heading\" data-id=\"b16c562\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.16.0 - 20-09-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">Please Fill Out the Form Below:<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-0a8e0e2 e-flex e-con-boxed e-con e-parent\" data-id=\"0a8e0e2\" data-element_type=\"container\" data-settings=\"{&quot;content_width&quot;:&quot;boxed&quot;}\" data-core-v316-plus=\"true\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-adddf77 elementor-widget elementor-widget-wpforms\" data-id=\"adddf77\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-elementor-widget-adddf77\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-adddf77 {\n\t\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-887\"><form id=\"wpforms-form-887\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"887\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/914\" data-token=\"3ab8b2ba5d97199522befb2842b48c5e\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-887-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Your Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-887-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-887-field_0-error\" required><label for=\"wpforms-887-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-887-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-887-field_0-last-error\" required><label for=\"wpforms-887-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-887-field_9-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">Child&#039;s Name (if applicable)<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-887-field_9\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][9][first]\" aria-errormessage=\"wpforms-887-field_9-error\" ><label for=\"wpforms-887-field_9\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-887-field_9-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][9][last]\" aria-errormessage=\"wpforms-887-field_9-last-error\" ><label for=\"wpforms-887-field_9-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-887-field_10-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Child&#039;s Age (if applicable)<\/legend><ul id=\"wpforms-887-field_10\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-887-field_10_1\" name=\"wpforms[fields][10]\" value=\"0-5 months\" aria-errormessage=\"wpforms-887-field_10_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_10_1\">0-5 months<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-887-field_10_2\" name=\"wpforms[fields][10]\" value=\"6-11 months\" aria-errormessage=\"wpforms-887-field_10_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_10_2\">6-11 months<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-887-field_10_3\" name=\"wpforms[fields][10]\" value=\"1-3 years\" aria-errormessage=\"wpforms-887-field_10_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_10_3\">1-3 years<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-887-field_10_4\" name=\"wpforms[fields][10]\" value=\"4-8 years\" aria-errormessage=\"wpforms-887-field_10_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_10_4\">4-8 years<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-887-field_10_5\" name=\"wpforms[fields][10]\" value=\"9 years or older\" aria-errormessage=\"wpforms-887-field_10_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_10_5\">9 years or older<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-887-field_17-container\" class=\"wpforms-field wpforms-field-payment-multiple\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Is your child enrolled in Baby Net?<\/legend><ul id=\"wpforms-887-field_17\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-887-field_17_1\" class=\"wpforms-payment-price\" data-amount=\"10.00\" name=\"wpforms[fields][17]\" value=\"1\" aria-errormessage=\"wpforms-887-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_17_1\">Yes<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-887-field_17_2\" class=\"wpforms-payment-price\" data-amount=\"25.00\" name=\"wpforms[fields][17]\" value=\"2\" aria-errormessage=\"wpforms-887-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_17_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-887-field_6-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">I am interested in:<\/legend><ul id=\"wpforms-887-field_6\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_6_1\" name=\"wpforms[fields][6][]\" value=\"Occupational Therapy\" aria-errormessage=\"wpforms-887-field_6_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_6_1\">Occupational Therapy<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_6_2\" name=\"wpforms[fields][6][]\" value=\"Speech Therapy\" aria-errormessage=\"wpforms-887-field_6_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_6_2\">Speech Therapy<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_6_3\" name=\"wpforms[fields][6][]\" value=\"Physical Therapy\" aria-errormessage=\"wpforms-887-field_6_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_6_3\">Physical Therapy<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_6_4\" name=\"wpforms[fields][6][]\" value=\"Lactation Services\" aria-errormessage=\"wpforms-887-field_6_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_6_4\">Lactation Services<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_6_5\" name=\"wpforms[fields][6][]\" value=\"Job Opportunities\" aria-errormessage=\"wpforms-887-field_6_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_6_5\">Job Opportunities<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_6_6\" name=\"wpforms[fields][6][]\" value=\"Fieldwork Experiences \/ Volunteer Work\" aria-errormessage=\"wpforms-887-field_6_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_6_6\">Fieldwork Experiences \/ Volunteer Work<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-887-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">My Availability:<\/legend><ul id=\"wpforms-887-field_16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Mornings (8am-11 am)\" aria-errormessage=\"wpforms-887-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_16_1\">Mornings (8am-11 am)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_16_2\" name=\"wpforms[fields][16][]\" value=\"Mid-day (11am- 1pm)\" aria-errormessage=\"wpforms-887-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_16_2\">Mid-day (11am- 1pm)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_16_3\" name=\"wpforms[fields][16][]\" value=\"Early Afternoon (1-3 pm)\" aria-errormessage=\"wpforms-887-field_16_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_16_3\">Early Afternoon (1-3 pm)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_16_4\" name=\"wpforms[fields][16][]\" value=\"Late Afternoon (3-6 pm)\" aria-errormessage=\"wpforms-887-field_16_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_16_4\">Late Afternoon (3-6 pm)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_16_7\" name=\"wpforms[fields][16][]\" value=\"My schedule is flexible.\" aria-errormessage=\"wpforms-887-field_16_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_16_7\">My schedule is flexible.<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-887-field_16_8\" name=\"wpforms[fields][16][]\" value=\"I am only available on certain days (i.e. Mondays only)\" aria-errormessage=\"wpforms-887-field_16_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-887-field_16_8\">I am only available on certain days (i.e. Mondays only)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-887-field_7-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-887-field_7\">Phone: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-887-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-887-field_7-error\" required><\/div><div id=\"wpforms-887-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"email\" id=\"wpforms-887-field_1\" class=\"wpforms-field-required wpforms-field-email-primary\" name=\"wpforms[fields][1][primary]\" spellcheck=\"false\" aria-errormessage=\"wpforms-887-field_1-error\" required><label for=\"wpforms-887-field_1\" class=\"wpforms-field-sublabel after \">Email<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"email\" id=\"wpforms-887-field_1-secondary\" class=\"wpforms-field-email-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-887-field_1\" name=\"wpforms[fields][1][secondary]\" spellcheck=\"false\" aria-errormessage=\"wpforms-887-field_1-secondary-error\" required><label for=\"wpforms-887-field_1-secondary\" class=\"wpforms-field-sublabel after \">Confirm Email<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-887-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-887-field_2\">Primary Concerns or Questions:<\/label><textarea id=\"wpforms-887-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-887-field_2-error\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"887\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-887\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/newheightspediatrictherapy.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Please Fill Out the Form Below: Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Your Name * FirstLast Child&#039;s Name (if applicable) FirstLast Child&#039;s Age (if applicable) 0-5 months 6-11 months 1-3 years 4-8 years 9 years or older Is your child enrolled in&hellip;&nbsp;<a href=\"https:\/\/newheightspediatrictherapy.com\/index.php\/contact-info-form\/\" class=\"\" rel=\"bookmark\">Read More &raquo;<span class=\"screen-reader-text\">Contact Info Form<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","_themeisle_gutenberg_block_has_review":false,"_ti_tpc_template_sync":false,"_ti_tpc_template_id":"","footnotes":""},"class_list":["post-914","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/pages\/914","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/comments?post=914"}],"version-history":[{"count":14,"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/pages\/914\/revisions"}],"predecessor-version":[{"id":1576,"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/pages\/914\/revisions\/1576"}],"wp:attachment":[{"href":"https:\/\/newheightspediatrictherapy.com\/index.php\/wp-json\/wp\/v2\/media?parent=914"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}