{"id":13,"date":"2020-12-29T00:50:50","date_gmt":"2020-12-29T00:50:50","guid":{"rendered":"https:\/\/teamrehabsolutions.com.au\/?page_id=13"},"modified":"2026-05-29T16:05:55","modified_gmt":"2026-05-29T06:05:55","slug":"refer-to-us","status":"publish","type":"page","link":"https:\/\/teamrehabsolutions.com.au\/staging\/refer-to-us\/","title":{"rendered":"Refer to Us"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"13\" class=\"elementor elementor-13\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3b9ab7a page-hero-banner e-flex e-con-boxed e-con e-parent\" data-id=\"3b9ab7a\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ee0a9f1 e-transform hero-banner-tagline elementor-widget elementor-widget-heading\" data-id=\"ee0a9f1\" data-element_type=\"widget\" data-settings=\"{&quot;_transform_translateY_effect_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:0,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_tablet_extra&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_mobile_extra&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateY_effect&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateY_effect_tablet_extra&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateY_effect_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateY_effect_mobile_extra&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">REFER TO US<\/h1>\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-635141b e-flex e-con-boxed e-con e-parent\" data-id=\"635141b\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-90e33ae elementor-widget__width-initial hline elementor-widget elementor-widget-heading\" data-id=\"90e33ae\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\"><strong>Unsure where to start?<\/strong>  Our team will guide you through the next steps in your journey<\/h2>\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-dece854 e-con-full e-flex e-con e-child\" data-id=\"dece854\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-21d0179 elementor-widget elementor-widget-global elementor-global-5337 elementor-widget-button\" data-id=\"21d0179\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#general-enquiry\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">General Enquiry<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-920d4d6 elementor-widget elementor-widget-global elementor-global-5350 elementor-widget-button\" data-id=\"920d4d6\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#referral-forms\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Ready to Refer<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\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-01b9a60 e-flex e-con-boxed e-con e-parent\" data-id=\"01b9a60\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a231533 elementor-headline--style-highlight elementor-widget elementor-widget-animated-headline\" data-id=\"a231533\" data-element_type=\"widget\" data-settings=\"{&quot;marker&quot;:&quot;underline&quot;,&quot;highlighted_text&quot;:&quot;REFERRAL&quot;,&quot;headline_style&quot;:&quot;highlight&quot;,&quot;loop&quot;:&quot;yes&quot;,&quot;highlight_animation_duration&quot;:1200,&quot;highlight_iteration_delay&quot;:8000}\" data-widget_type=\"animated-headline.default\">\n\t\t\t\t\t\t\t<h3 class=\"elementor-headline\">\n\t\t\t\t<span class=\"elementor-headline-dynamic-wrapper elementor-headline-text-wrapper\">\n\t\t\t\t\t<span class=\"elementor-headline-dynamic-text elementor-headline-text-active\">REFERRAL<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t\t<span class=\"elementor-headline-plain-text elementor-headline-text-wrapper\">FORM<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-271aa47 elementor-widget elementor-widget-text-editor\" data-id=\"271aa47\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>We have immediate capacity to welcome new patients into the Team Rehab Solutions community. Our streamlined administrative systems and highly supported clinical team ensure your clients receive consistent, high-quality care without long wait times.<\/p><p>We accept referrals from general practitioners, specialists, practice nurses, allied health professionals, case managers, discharge coordinators, and community health organisations.<\/p><p>We understand that timely communication is essential for effective patient care, which is why we offer a two-hour response time for online referrals during business hours and ensure all clients are contacted within 24 hours of a referral being received.<\/p><p>To get started, please complete the form below or call us on 1300 685 046 to discuss how we can work together to achieve the best possible outcomes for your patients.<\/p>\t\t\t\t\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-ec6e467 e-flex e-con-boxed e-con e-parent\" data-id=\"ec6e467\" data-element_type=\"container\" id=\"referral-forms\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ac12fa0 e-n-tabs-none elementor-widget elementor-widget-n-tabs\" data-id=\"ac12fa0\" data-element_type=\"widget\" data-settings=\"{&quot;horizontal_scroll_mobile&quot;:&quot;disable&quot;,&quot;horizontal_scroll&quot;:&quot;disable&quot;}\" data-widget_type=\"nested-tabs.default\">\n\t\t\t\t\t\t\t<div class=\"e-n-tabs\" data-widget-number=\"180432800\" aria-label=\"Tabs. Open items with Enter or Space, close with Escape and navigate using the Arrow keys.\">\n\t\t\t<div class=\"e-n-tabs-heading\" role=\"tablist\">\n\t\t\t\t\t<button id=\"e-n-tab-title-1804328001\" data-tab-title-id=\"e-n-tab-title-1804328001\" class=\"e-n-tab-title\" aria-selected=\"true\" data-tab-index=\"1\" role=\"tab\" tabindex=\"0\" aria-controls=\"e-n-tab-content-1804328001\" style=\"--n-tabs-title-order: 1;\">\n\t\t\t\t\t\t<span class=\"e-n-tab-title-text\">\n\t\t\t\tNDIS\t\t\t<\/span>\n\t\t<\/button>\n\t\t\t\t<button id=\"e-n-tab-title-1804328002\" data-tab-title-id=\"e-n-tab-title-1804328002\" class=\"e-n-tab-title\" aria-selected=\"false\" data-tab-index=\"2\" role=\"tab\" tabindex=\"-1\" aria-controls=\"e-n-tab-content-1804328002\" style=\"--n-tabs-title-order: 2;\">\n\t\t\t\t\t\t<span class=\"e-n-tab-title-text\">\n\t\t\t\tSupport At Home\t\t\t<\/span>\n\t\t<\/button>\n\t\t\t\t<button id=\"e-n-tab-title-1804328003\" data-tab-title-id=\"e-n-tab-title-1804328003\" class=\"e-n-tab-title\" aria-selected=\"false\" data-tab-index=\"3\" role=\"tab\" tabindex=\"-1\" aria-controls=\"e-n-tab-content-1804328003\" style=\"--n-tabs-title-order: 3;\">\n\t\t\t\t\t\t<span class=\"e-n-tab-title-text\">\n\t\t\t\tPrivate Patients\t\t\t<\/span>\n\t\t<\/button>\n\t\t\t\t\t<\/div>\n\t\t\t<div class=\"e-n-tabs-content\">\n\t\t\t\t<div id=\"e-n-tab-content-1804328001\" role=\"tabpanel\" aria-labelledby=\"e-n-tab-title-1804328001\" data-tab-index=\"1\" style=\"--n-tabs-title-order: 1;\" class=\"e-active elementor-element elementor-element-4b171b7 e-con-full e-flex e-con e-child\" data-id=\"4b171b7\" data-element_type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-9e2b044 e-flex e-con-boxed e-con e-child\" data-id=\"9e2b044\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5ad30f2 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"5ad30f2\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">NDIS REFERRAL FORM<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-af0f161 elementor-widget elementor-widget-shortcode\" data-id=\"af0f161\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_14' style='display:none'><div id='gf_14' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_14' id='gform_14'  action='\/staging\/wp-json\/wp\/v2\/pages\/13#gf_14' data-formid='14' novalidate>\n        <div id='gf_progressbar_wrapper_14' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_14_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_85\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Participant\/Client Details<\/h3><div class='gsection_description' id='gfield_description_14_85'>Please complete the information below to begin your referral.<\/div><\/div><div id=\"field_14_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_2'>Participant\/Client Name<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_14_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_152\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_152'>Date of Birth<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_14_152' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_91\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_91'>Please Describe the Clients Gender<\/label><div class='ginput_container ginput_container_select'><select name='input_91' id='input_14_91' class='small gfield_select'     aria-invalid=\"false\" ><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_14_92\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_92'>Aboriginal or Torres Strait Islander Origin<\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_14_92' class='small gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_14_93\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_93'>Area<\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_14_93' class='small gfield_select'     aria-invalid=\"false\" ><option value='Sunshine Coast' >Sunshine Coast<\/option><option value='Fraser Coast' >Fraser Coast<\/option><option value='Gympie' >Gympie<\/option><option value='Moreton Bay' >Moreton Bay<\/option><option value='Brisbane' >Brisbane<\/option><option value='Gold Coast' >Gold Coast<\/option><option value='Northern NSW' >Northern NSW<\/option><\/select><\/div><\/div><div id=\"field_14_101\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_101'>Participant\/Client Email<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_14_101' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_102\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_102'>Participant\/Client Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_14_102' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_99\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_14_99' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_99_1_container' >\n                                        <input type='text' name='input_99.1' id='input_14_99_1' value=''    aria-required='false'    \/>\n                                        <label for='input_14_99_1' id='input_14_99_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_99_3_container' >\n                                    <input type='text' name='input_99.3' id='input_14_99_3' value=''    aria-required='false'    \/>\n                                    <label for='input_14_99_3' id='input_14_99_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_99_4_container' >\n                                        <input type='text' name='input_99.4' id='input_14_99_4' value=''      aria-required='false'    \/>\n                                        <label for='input_14_99_4' id='input_14_99_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_99_5_container' >\n                                    <input type='text' name='input_99.5' id='input_14_99_5' value=''    aria-required='false'    \/>\n                                    <label for='input_14_99_5' id='input_14_99_5_label' class='gform-field-label gform-field-label--type-sub '>Post Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_14_99_6_container' >\n                                        <select name='input_99.6' id='input_14_99_6'   aria-required='false'    ><option value='' selected='selected'><\/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' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic 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='Czechia' >Czechia<\/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' >Eswatini<\/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 Island and McDonald Islands' >Heard Island 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='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/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='Macao' >Macao<\/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 Macedonia' >North Macedonia<\/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='Russian Federation' >Russian Federation<\/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, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/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 and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/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' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/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='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/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' >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='Viet Nam' >Viet Nam<\/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_14_99_6' id='input_14_99_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_14_145\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_145'>How did you find out about TRS?<\/label><div class='ginput_container ginput_container_select'><select name='input_145' id='input_14_145' class='small gfield_select'     aria-invalid=\"false\" ><option value='Support Coordinator' >Support Coordinator<\/option><option value='Word of Mouth' >Word of Mouth<\/option><option value='Google' >Google<\/option><option value='GP \/ Specialist' >GP \/ Specialist<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_14_105' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_14_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_2' class='gform_page' data-js='page-field-id-105' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_87\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">NDIS Details<\/h3><\/div><div id=\"field_14_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_3'>NDIS Number<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_14_3' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >The NDIS Plan is:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_11'><div class='gchoice gchoice_14_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Yes'  id='choice_14_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_11_1' id='label_14_11_1' class='gform-field-label gform-field-label--type-inline'>Self-Managed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Yes'  id='choice_14_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_11_2' id='label_14_11_2' class='gform-field-label gform-field-label--type-inline'>Plan Managed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Yes'  id='choice_14_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_11_3' id='label_14_11_3' class='gform-field-label gform-field-label--type-inline'>Agency Managed<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_111\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >NDIS Funding Approved<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_111'>\n\t\t\t<div class='gchoice gchoice_14_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Yes'  id='choice_14_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_111_0' id='label_14_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='No'  id='choice_14_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_111_1' id='label_14_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_112\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >NDIS Report Required<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_112'>\n\t\t\t<div class='gchoice gchoice_14_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Yes'  id='choice_14_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_112_0' id='label_14_112_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='No'  id='choice_14_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_112_1' id='label_14_112_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_113\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your plan registered on the PACE System?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_113'>\n\t\t\t<div class='gchoice gchoice_14_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Yes'  id='choice_14_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_113_0' id='label_14_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='No'  id='choice_14_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_113_1' id='label_14_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_115\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Services You Require<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_115'><div class='gchoice gchoice_14_115_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.1' type='checkbox'  value='Physiotherapy'  id='choice_14_115_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_115_1' id='label_14_115_1' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_115_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.2' type='checkbox'  value='Occupational Therapy'  id='choice_14_115_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_115_2' id='label_14_115_2' class='gform-field-label gform-field-label--type-inline'>Occupational Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_115_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.3' type='checkbox'  value='Exercise Physiology'  id='choice_14_115_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_115_3' id='label_14_115_3' class='gform-field-label gform-field-label--type-inline'>Exercise Physiology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_115_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.4' type='checkbox'  value='Podiatry'  id='choice_14_115_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_115_4' id='label_14_115_4' class='gform-field-label gform-field-label--type-inline'>Podiatry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_115_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.5' type='checkbox'  value='Dietitian'  id='choice_14_115_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_115_5' id='label_14_115_5' class='gform-field-label gform-field-label--type-inline'>Dietitian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_115_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.6' type='checkbox'  value='Speech Pathology'  id='choice_14_115_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_115_6' id='label_14_115_6' class='gform-field-label gform-field-label--type-inline'>Speech Pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_118\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Additional Requirements<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_118'><div class='gchoice gchoice_14_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='Functional Capacity Report'  id='choice_14_118_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_118_1' id='label_14_118_1' class='gform-field-label gform-field-label--type-inline'>Functional Capacity Report<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='Therapy'  id='choice_14_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_118_2' id='label_14_118_2' class='gform-field-label gform-field-label--type-inline'>Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_118_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.3' type='checkbox'  value='Home Modifications'  id='choice_14_118_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_118_3' id='label_14_118_3' class='gform-field-label gform-field-label--type-inline'>Home Modifications<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_118_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.4' type='checkbox'  value='Assistive Technology'  id='choice_14_118_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_118_4' id='label_14_118_4' class='gform-field-label gform-field-label--type-inline'>Assistive Technology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_118_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.5' type='checkbox'  value='Other'  id='choice_14_118_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_118_5' id='label_14_118_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Functional Capacity Report<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_119'>\n\t\t\t<div class='gchoice gchoice_14_119_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='Initial Report'  id='choice_14_119_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_0' id='label_14_119_0' class='gform-field-label gform-field-label--type-inline'>Initial Report<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_119_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='FCA'  id='choice_14_119_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_1' id='label_14_119_1' class='gform-field-label gform-field-label--type-inline'>FCA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_119_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='SIL'  id='choice_14_119_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_2' id='label_14_119_2' class='gform-field-label gform-field-label--type-inline'>SIL<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_119_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='SDA'  id='choice_14_119_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_3' id='label_14_119_3' class='gform-field-label gform-field-label--type-inline'>SDA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_119_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='gf_other_choice'  id='choice_14_119_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_4' id='label_14_119_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_14_119_other' class='gchoice_other_control' name='input_119_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Therapy<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_121'>\n\t\t\t<div class='gchoice gchoice_14_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Life Skills Therapy (Budgeting, Meal Prep, Personal Organisation'  id='choice_14_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_0' id='label_14_121_0' class='gform-field-label gform-field-label--type-inline'>Life Skills Therapy (Budgeting, Meal Prep, Personal Organisation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Upper Limb Rehabilitation'  id='choice_14_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_1' id='label_14_121_1' class='gform-field-label gform-field-label--type-inline'>Upper Limb Rehabilitation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_121_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Cognitive Rehabilitation'  id='choice_14_121_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_2' id='label_14_121_2' class='gform-field-label gform-field-label--type-inline'>Cognitive Rehabilitation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_121_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Fatigue Management \/ Sleep Hygiene'  id='choice_14_121_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_3' id='label_14_121_3' class='gform-field-label gform-field-label--type-inline'>Fatigue Management \/ Sleep Hygiene<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_121_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='gf_other_choice'  id='choice_14_121_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_4' id='label_14_121_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_14_121_other' class='gchoice_other_control' name='input_121_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Home Modifications<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_122'>\n\t\t\t<div class='gchoice gchoice_14_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Minor Mod (removable ramp, grab rails, non-structural changes)'  id='choice_14_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_122_0' id='label_14_122_0' class='gform-field-label gform-field-label--type-inline'>Minor Mod (removable ramp, grab rails, non-structural changes)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Major Mods (bathroom modification, concrete ramp, door widening\/automation, high-cost structural building changes)'  id='choice_14_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_122_1' id='label_14_122_1' class='gform-field-label gform-field-label--type-inline'>Major Mods (bathroom modification, concrete ramp, door widening\/automation, high-cost structural building changes)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Assistive Technology<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_123'>\n\t\t\t<div class='gchoice gchoice_14_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Low Cost AT \/ Simple (dressing aids, adaptive kitchen aids, low cost mobility aids including 4WW and walking stick'  id='choice_14_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_123_0' id='label_14_123_0' class='gform-field-label gform-field-label--type-inline'>Low Cost AT \/ Simple (dressing aids, adaptive kitchen aids, low cost mobility aids including 4WW and walking stick<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='High Cost \/ Complex AT (mobility scooter or powered wheelchair)'  id='choice_14_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_123_1' id='label_14_123_1' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (mobility scooter or powered wheelchair)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_123_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='High Cost \/ Complex AT (manual wheelchair)'  id='choice_14_123_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_123_2' id='label_14_123_2' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (manual wheelchair)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_123_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='High Cost \/ Complex AT (mobile shower commode)'  id='choice_14_123_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_123_3' id='label_14_123_3' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (mobile shower commode)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_123_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='High Cost \/ Complex AT (manual floor hoist)'  id='choice_14_123_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_123_4' id='label_14_123_4' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (manual floor hoist)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_123_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='High Cost \/ Complex AT (other)'  id='choice_14_123_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_123_5' id='label_14_123_5' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (other)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Other<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_124'>\n\t\t\t<div class='gchoice gchoice_14_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Behaviour Support'  id='choice_14_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_0' id='label_14_124_0' class='gform-field-label gform-field-label--type-inline'>Behaviour Support<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Driving Assessment and\/or Vehicle Modifications'  id='choice_14_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_1' id='label_14_124_1' class='gform-field-label gform-field-label--type-inline'>Driving Assessment and\/or Vehicle Modifications<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='NDIS Access Report (to be submitted to the NDIA with an access request - this report is for individuals who are not yet participants of the NDIS'  id='choice_14_124_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_2' id='label_14_124_2' class='gform-field-label gform-field-label--type-inline'>NDIS Access Report (to be submitted to the NDIA with an access request - this report is for individuals who are not yet participants of the NDIS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='gf_other_choice'  id='choice_14_124_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_3' id='label_14_124_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_14_124_other' class='gchoice_other_control' name='input_124_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_125'>Reason for visit and NDIS Goals<\/label><div class='gfield_description' id='gfield_description_14_125'>What do you hope to achieve from the Physio\/OT\/EP\/Podiatry\/Dietitian\/Speech Pathology appointment?<\/div><div class='ginput_container ginput_container_text'><input name='input_125' id='input_14_125' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_125\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_126\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_126'>Primary Diagnosis<\/label><div class='gfield_description' id='gfield_description_14_126'>This is the disability you have met access to the NDIS for.<\/div><div class='ginput_container ginput_container_text'><input name='input_126' id='input_14_126' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_126\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_127\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_127'>General Medical History<\/label><div class='gfield_description' id='gfield_description_14_127'>Please share any relevant medical history\/diagnosis (please include Mental Health history) that would be beneficial for the clinician to be aware of.<\/div><div class='ginput_container ginput_container_text'><input name='input_127' id='input_14_127' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_127\"    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_14_116' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_14_116' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_14_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_3' class='gform_page' data-js='page-field-id-116' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_117\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Support Coordinator Details<\/h3><div class='gsection_description' id='gfield_description_14_117'>Please complete this section if applicable.<\/div><\/div><div id=\"field_14_7\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_7'>Support Coordinator Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_14_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_8\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_8'>Support Coordinator Name<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_14_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_9'>Support Coordinator Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_14_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_10'>Support Coordinator Email<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_14_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_166\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Plan Manager Details<\/h3><div class='gsection_description' id='gfield_description_14_166'>Please complete this section if applicable.<\/div><\/div><div id=\"field_14_14\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_14'>Plan Manager Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_14_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_15'>Plan Manager Address<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_14_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_16\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_16'>Plan Manager Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_14_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_17\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_17'>Plan Manager Email<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_14_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_24\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_24'>Participant Name<\/label><div class='gfield_description' id='gfield_description_14_24'>Please complete to acknowledge your agreement of the above.<\/div><div class='ginput_container ginput_container_text'><input name='input_24' id='input_14_24' type='text' value='' class='medium'  aria-describedby=\"gfield_description_14_24\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_153\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_153'>Date of Birth<\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_14_153' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_14_109' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_14_109' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_14_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_4' class='gform_page' data-js='page-field-id-109' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_128\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Home Visit Safety Checklist<\/h3><\/div><fieldset id=\"field_14_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is there parking available on-site? Is the property visible from the street?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_154'>\n\t\t\t<div class='gchoice gchoice_14_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Yes'  id='choice_14_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_154_0' id='label_14_154_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='No'  id='choice_14_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_154_1' id='label_14_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_131\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_14_131'>Please provide further information<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_14_131' type='text' value='' class='large'    placeholder='Please provide further information'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_155\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is there Phone Reception on the Property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_155'>\n\t\t\t<div class='gchoice gchoice_14_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Yes'  id='choice_14_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_155_0' id='label_14_155_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='No'  id='choice_14_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_155_1' id='label_14_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are There Pets in the House?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_156'>\n\t\t\t<div class='gchoice gchoice_14_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_14_156_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_14_156\"   \/>\n\t\t\t\t\t<label for='choice_14_156_0' id='label_14_156_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_14_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_156_1' id='label_14_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_14_156'>We kindly requst that dogs\/cats be put away during the clinicians visit.<\/div><\/fieldset><fieldset id=\"field_14_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will anyone else be present during the appointment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_158'>\n\t\t\t<div class='gchoice gchoice_14_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Yes'  id='choice_14_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_158_0' id='label_14_158_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_14_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_158_1' id='label_14_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_14_136'>Name and Relationship to the Client<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_14_136' type='text' value='' class='large'    placeholder='Name and Relationship to the Client'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client a smoker?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_159'>\n\t\t\t<div class='gchoice gchoice_14_159_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='Yes'  id='choice_14_159_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_14_159\"   \/>\n\t\t\t\t\t<label for='choice_14_159_0' id='label_14_159_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_159_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='No'  id='choice_14_159_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_159_1' id='label_14_159_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_14_159'>Please kindly refrain from smoking during the home visit as it is part of workplace safety regulations. Any breaches will result in termination of the home visit, with applicable charges still applying.<\/div><\/fieldset><fieldset id=\"field_14_160\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone on the property have a criminal history?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_160'>\n\t\t\t<div class='gchoice gchoice_14_160_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='Yes'  id='choice_14_160_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_160_0' id='label_14_160_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_160_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='No'  id='choice_14_160_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_160_1' id='label_14_160_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_139\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_14_139'>Please Provide Details<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_14_139' type='text' value='' class='large'    placeholder='Please Provide Details'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_161\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are there any firearms or weapons stored on the property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_161'>\n\t\t\t<div class='gchoice gchoice_14_161_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='Yes'  id='choice_14_161_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_161_0' id='label_14_161_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_161_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='No'  id='choice_14_161_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_161_1' id='label_14_161_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_14_162'>Please confirm they will be securely stored\/locked as per relevant laws.<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_14_162' type='text' value='' class='large'    placeholder='Please confirm they will be securely stored\/locked as per relevant laws.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone living in the house have a history of abuse, aggression, challenging behaviours, excessive drug\/alcohol use or violence that may impact work safety?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_163'>\n\t\t\t<div class='gchoice gchoice_14_163_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='Yes'  id='choice_14_163_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_163_0' id='label_14_163_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_163_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='No'  id='choice_14_163_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_163_1' id='label_14_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_14_142'>Please Provide Details<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_14_142' type='text' value='' class='large'    placeholder='Please Provide Details'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone living in the house have an infectious disease (Eg. COVID, MRSA)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_164'>\n\t\t\t<div class='gchoice gchoice_14_164_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='Yes'  id='choice_14_164_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_164_0' id='label_14_164_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_164_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='No'  id='choice_14_164_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_164_1' id='label_14_164_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_165\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_14_165'>Please Provide Details<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_14_165' type='text' value='' class='large'    placeholder='Please Provide Details'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_144'>Other Comments?<\/label><div class='gfield_description' id='gfield_description_14_144'>Is there anything else that the therapist needs to be aware of prior to attending the home visit?<\/div><div class='ginput_container ginput_container_text'><input name='input_144' id='input_14_144' type='text' value='' class='large'  aria-describedby=\"gfield_description_14_144\"    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_14_130' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_14_130' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_14_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_5' class='gform_page' data-js='page-field-id-130' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_106\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Emergency &amp; Disaster Plan<\/h3><div class='gsection_description' id='gfield_description_14_106'>In some circumstances where there may be a disruption to the Participants care such as in natural disasters or pandemics. In such events the Provider will endeavour to prioritise the Participants preferences for continuity of care. Please indicate with descending numbers where 1 is the highest preference. This is so we can work with you to ensure your preferences are taken into consideration when these unfortunate events occur. Please only use each number once.<\/div><\/div><div id=\"field_14_80\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_80'>Via telehealth with another clinician<\/label><div class='ginput_container ginput_container_number'><input name='input_80' id='input_14_80' type='number' step='any' min='1' max='5' value='' class='small'    placeholder='1-5'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_14_80\" \/><div class='gfield_description instruction ' id='gfield_instruction_14_80'>Please enter a number from <strong>1<\/strong> to <strong>5<\/strong>.<\/div><\/div><\/div><div id=\"field_14_81\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_81'>Via telehealth with current clinician<\/label><div class='ginput_container ginput_container_number'><input name='input_81' id='input_14_81' type='number' step='any' min='1' max='5' value='' class='small'    placeholder='1-5'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_14_81\" \/><div class='gfield_description instruction ' id='gfield_instruction_14_81'>Please enter a number from <strong>1<\/strong> to <strong>5<\/strong>.<\/div><\/div><\/div><div id=\"field_14_82\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_82'>Next available appointment in home setting<\/label><div class='ginput_container ginput_container_number'><input name='input_82' id='input_14_82' type='number' step='any' min='1' max='5' value='' class='small'    placeholder='1-5'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_14_82\" \/><div class='gfield_description instruction ' id='gfield_instruction_14_82'>Please enter a number from <strong>1<\/strong> to <strong>5<\/strong>.<\/div><\/div><\/div><div id=\"field_14_83\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_83'>Next available nearest clinical setting<\/label><div class='ginput_container ginput_container_number'><input name='input_83' id='input_14_83' type='number' step='any' min='1' max='5' value='' class='small'    placeholder='1-5'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_14_83\" \/><div class='gfield_description instruction ' id='gfield_instruction_14_83'>Please enter a number from <strong>1<\/strong> to <strong>5<\/strong>.<\/div><\/div><\/div><div id=\"field_14_84\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_84'>Wait until current clinician available<\/label><div class='ginput_container ginput_container_number'><input name='input_84' id='input_14_84' type='number' step='any' min='1' max='5' value='' class='small'    placeholder='1-5'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_14_84\" \/><div class='gfield_description instruction ' id='gfield_instruction_14_84'>Please enter a number from <strong>1<\/strong> to <strong>5<\/strong>.<\/div><\/div><\/div><div id=\"field_14_31\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_31'>Emergency Contact Name<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_14_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_32\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_32'>Emergency Contact Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_14_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_14_110' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_14_110' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_14_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_6' class='gform_page' data-js='page-field-id-110' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_86\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent to Contact Stakeholders<\/h3><div class='gsection_description' id='gfield_description_14_86'>Please complete the required information below for  the list of contacts you consent for us to share information with:<\/div><\/div><div id=\"field_14_35\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_35'>Nominated Family Member or Support Person<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_14_35' type='text' value='' class='medium'    placeholder='Enter Name Here'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_36'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_14_36' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_37\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_37'>Public Guardian or Advocate<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_14_37' type='text' value='' class='medium'    placeholder='Enter Name Here'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_38'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_14_38' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_39\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_39'>Support Coordinator<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_14_39' type='text' value='' class='medium'    placeholder='Enter Name Here'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_40'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_14_40' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_41'>NDIA<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_14_41' type='text' value='' class='medium'    placeholder='Enter Name Here'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_42\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_42'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_14_42' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_43\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_43'>Health Practitioner<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_14_43' type='text' value='' class='medium'  aria-describedby=\"gfield_description_14_43\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_14_43'>Enter Name Here<\/div><\/div><div id=\"field_14_44\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_44'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_14_44' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_45\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_45'>General Practitioner<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_14_45' type='text' value='' class='medium'    placeholder='Enter Name Here'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_46'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_14_46' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_47\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_47'>Psychologist<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_14_47' type='text' value='' class='medium'  aria-describedby=\"gfield_description_14_47\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_14_47'>Enter Name Here<\/div><\/div><div id=\"field_14_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_48'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_14_48' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_49'>School or Preschool<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_14_49' type='text' value='' class='medium'    placeholder='Enter Name Here'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_50\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_50'>Contact Details<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_14_50' type='text' value='' class='medium'    placeholder='Phone or Email'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_57'>Name of Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_14_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_14_149' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_14_149' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_14_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_14_7' class='gform_page' data-js='page-field-id-149' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_14_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_151\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Form Completion<\/h3><\/div><div id=\"field_14_147\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_147'>Form Completed By<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_14_147' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_148\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_148'>Your Email Address<\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_14_148' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_150\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_150'>Please attach any relevant documentation<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_150' id='input_14_150' type='file' class='large' aria-describedby=\"gfield_upload_rules_14_150\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_14_150'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_14_150'><\/div> <\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_14' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_14' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <button type='button'  id='gform_save_14_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save & Continue Later<\/button><input type='hidden' name='gform_ajax' value='form_id=14&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=442934ad421459716afdaa4da483ed2e' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_14' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_14' id='gform_theme_14' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_14' id='gform_style_settings_14' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_14' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='14' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_14' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_14' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='AUD' value='zEMK1p3i2QQGDPfss7z\/5629fq18r39KyVixgoBl2omHea1Sx9kCNP6dh7in6VAuLfK2ICP0yQoFUJVF5Q2knQ7tGVmPv\/rT2QEx5FxBugP6ejk=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_14' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_14' id='gform_target_page_number_14' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_14' id='gform_source_page_number_14' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_14' id='gform_ajax_frame_14' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 14, 'https:\/\/teamrehabsolutions.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_14').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_14');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_14').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_14').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_14').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_14').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_14').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_14').val();gformInitSpinner( 14, 'https:\/\/teamrehabsolutions.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [14, current_page]);window['gf_submitting_14'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_14').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_14').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [14]);window['gf_submitting_14'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_14').text());}else{jQuery('#gform_14').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"14\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_14\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_14\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_14\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;        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{                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div id=\"e-n-tab-content-1804328002\" role=\"tabpanel\" aria-labelledby=\"e-n-tab-title-1804328002\" data-tab-index=\"2\" style=\"--n-tabs-title-order: 2;\" class=\" elementor-element elementor-element-c70c2d5 e-con-full e-flex e-con e-child\" data-id=\"c70c2d5\" data-element_type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-427096b e-flex e-con-boxed e-con e-child\" data-id=\"427096b\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b652953 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"b652953\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">SUPPORT AT HOME REFERRAL FORM<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6b2adfe elementor-widget elementor-widget-shortcode\" data-id=\"6b2adfe\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework body_wrapper .gform_wrapper_wrapper .gform_body_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8' class='body .gform_wrapper .gform_body' action='\/staging\/wp-json\/wp\/v2\/pages\/13#gf_8' data-formid='8' novalidate>\n        <div id='gf_progressbar_wrapper_8' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_8_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_94\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_94'>Facebook<\/label><div class='ginput_container'><input name='input_94' id='input_8_94' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_8_94'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_8_78\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient\/Client Details<\/h3><\/div><fieldset id=\"field_8_1\" class=\"gfield gfield--type-name gfield--input-type-name .form-text-increase field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_1'>\n                            \n                            <span id='input_8_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_8_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_8_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_62\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_62'>Title<\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_8_62' class='small gfield_select'     aria-invalid=\"false\" ><option value='Mr' >Mr<\/option><option value='Mrs' >Mrs<\/option><option value='Miss' >Miss<\/option><option value='Ms' >Ms<\/option><option value='Dr' >Dr<\/option><\/select><\/div><\/div><div id=\"field_8_12\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_12'>Patient&#039;s Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_8_12' type='email' value='' class='small'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_3'>Patient&#039;s Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_8_3' type='tel' value='' class='small'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_60'>Client&#039;s General Practitioner (GP)<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_8_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_61'>Medical Centre<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_8_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_59\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_59'>Would the client like SMS Reminders<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_8_59' class='small gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_8_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_4'>Date Of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_8_4' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_4_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_4_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_4' class='gform_hidden' value='https:\/\/teamrehabsolutions.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_20'>Gender<\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_8_20' class='small gfield_select'     aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_8_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_21'>Aboriginal or Torres Strait Islander Origin<\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_8_21' class='small gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_8_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_14'>Area<\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_8_14' class='small gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Select Your Area<\/option><option value='Sunshine Coast' >Sunshine Coast<\/option><option value='Fraser Coast' >Fraser Coast<\/option><option value='Gympie' >Gympie<\/option><option value='Brisbane' >Brisbane<\/option><option value='Gold Coast' >Gold Coast<\/option><option value='Northern NSW' >Northern NSW<\/option><\/select><\/div><\/div><fieldset id=\"field_8_22\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_8_22' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_22_1_container' >\n                                        <input type='text' name='input_22.1' id='input_8_22_1' value=''    aria-required='false'    \/>\n                                        <label for='input_8_22_1' id='input_8_22_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_22_3_container' >\n                                    <input type='text' name='input_22.3' id='input_8_22_3' value=''    aria-required='false'    \/>\n                                    <label for='input_8_22_3' id='input_8_22_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_8_22_4_container' >\n                                        <input type='text' name='input_22.4' id='input_8_22_4' value=''      aria-required='false'    \/>\n                                        <label for='input_8_22_4' id='input_8_22_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_8_22_5_container' >\n                                    <input type='text' name='input_22.5' id='input_8_22_5' value=''    aria-required='false'    \/>\n                                    <label for='input_8_22_5' id='input_8_22_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_22.6' id='input_8_22_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_8_80' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_8_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_2' class='gform_page' data-js='page-field-id-80' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_65\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SAH Requirements<\/h3><\/div><fieldset id=\"field_8_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Invoicing Details<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_10'><div class='gchoice gchoice_8_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Client is on a home care package'  id='choice_8_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_10_1' id='label_8_10_1' class='gform-field-label gform-field-label--type-inline'>Client is on a home care package<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Other'  id='choice_8_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_10_2' id='label_8_10_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_74'>Home Care Package provider:<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_8_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_73'>Invoices to be sent to:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_8_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Referral Details<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_9'><div class='gchoice gchoice_8_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Physiotherapy'  id='choice_8_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_1' id='label_8_9_1' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Occupational Therapy'  id='choice_8_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_2' id='label_8_9_2' class='gform-field-label gform-field-label--type-inline'>Occupational Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Exercise Physiology'  id='choice_8_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_3' id='label_8_9_3' class='gform-field-label gform-field-label--type-inline'>Exercise Physiology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Podiatry'  id='choice_8_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_4' id='label_8_9_4' class='gform-field-label gform-field-label--type-inline'>Podiatry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Dietitian'  id='choice_8_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_5' id='label_8_9_5' class='gform-field-label gform-field-label--type-inline'>Dietitian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Remedial Massage'  id='choice_8_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_6' id='label_8_9_6' class='gform-field-label gform-field-label--type-inline'>Remedial Massage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Speech Pathology'  id='choice_8_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_9_7' id='label_8_9_7' class='gform-field-label gform-field-label--type-inline'>Speech Pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Additional Requirements<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_29'><div class='gchoice gchoice_8_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Report'  id='choice_8_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_29_1' id='label_8_29_1' class='gform-field-label gform-field-label--type-inline'>Report<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Therapy'  id='choice_8_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_29_2' id='label_8_29_2' class='gform-field-label gform-field-label--type-inline'>Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Home Modifications'  id='choice_8_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_29_3' id='label_8_29_3' class='gform-field-label gform-field-label--type-inline'>Home Modifications<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Assistive Technology'  id='choice_8_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_29_4' id='label_8_29_4' class='gform-field-label gform-field-label--type-inline'>Assistive Technology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Other'  id='choice_8_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_29_5' id='label_8_29_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_66'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_8_66' type='text' value='' class='large'    placeholder='Please specify'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Therapy<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_48'>\n\t\t\t<div class='gchoice gchoice_8_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Life Skills Therapy (Budgeting, Meal Prep, Personal Organisation'  id='choice_8_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_48_0' id='label_8_48_0' class='gform-field-label gform-field-label--type-inline'>Life Skills Therapy (Budgeting, Meal Prep, Personal Organisation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Upper Limb Rehabilitation'  id='choice_8_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_48_1' id='label_8_48_1' class='gform-field-label gform-field-label--type-inline'>Upper Limb Rehabilitation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Cognitive Rehabilitation'  id='choice_8_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_48_2' id='label_8_48_2' class='gform-field-label gform-field-label--type-inline'>Cognitive Rehabilitation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_48_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Fatigue Management \/ Sleep Hygiene'  id='choice_8_48_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_48_3' id='label_8_48_3' class='gform-field-label gform-field-label--type-inline'>Fatigue Management \/ Sleep Hygiene<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Home Modifications<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_49'>\n\t\t\t<div class='gchoice gchoice_8_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Minor Mod (removable ramp, grab rails, non-structural changes'  id='choice_8_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_49_0' id='label_8_49_0' class='gform-field-label gform-field-label--type-inline'>Minor Mod (removable ramp, grab rails, non-structural changes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Major Mods (bathroom modification, concrete ramp, door widening\/automation, high-cost structural building changes'  id='choice_8_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_49_1' id='label_8_49_1' class='gform-field-label gform-field-label--type-inline'>Major Mods (bathroom modification, concrete ramp, door widening\/automation, high-cost structural building changes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Assistive Technology<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_50'>\n\t\t\t<div class='gchoice gchoice_8_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Low Cost AT \/ Simple (dressing aids, adaptive kitchen aids, low cost mobility aids including 4WW and walking stick'  id='choice_8_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_50_0' id='label_8_50_0' class='gform-field-label gform-field-label--type-inline'>Low Cost AT \/ Simple (dressing aids, adaptive kitchen aids, low cost mobility aids including 4WW and walking stick<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='High Cost \/ Complex AT (mobility scooter or powered wheelchair)'  id='choice_8_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_50_1' id='label_8_50_1' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (mobility scooter or powered wheelchair)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='High Cost \/ Complex AT (manual wheelchair)'  id='choice_8_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_50_2' id='label_8_50_2' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (manual wheelchair)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='High Cost \/ Complex AT (mobile shower commode)'  id='choice_8_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_50_3' id='label_8_50_3' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (mobile shower commode)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_50_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='High Cost \/ Complex AT (manual floor hoist)'  id='choice_8_50_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_50_4' id='label_8_50_4' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (manual floor hoist)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_50_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='High Cost \/ Complex AT (other)'  id='choice_8_50_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_50_5' id='label_8_50_5' class='gform-field-label gform-field-label--type-inline'>High Cost \/ Complex AT (other)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Other<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_51'>\n\t\t\t<div class='gchoice gchoice_8_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Standard Initial OT Assessment &amp; Report (general assessment of function, environment, OT recommendations and accompanying report)'  id='choice_8_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_51_0' id='label_8_51_0' class='gform-field-label gform-field-label--type-inline'>Standard Initial OT Assessment &amp; Report (general assessment of function, environment, OT recommendations and accompanying report)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Behaviour Support'  id='choice_8_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_51_1' id='label_8_51_1' class='gform-field-label gform-field-label--type-inline'>Behaviour Support<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Driving Assessment and\/or Vehicle Modifications'  id='choice_8_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_51_2' id='label_8_51_2' class='gform-field-label gform-field-label--type-inline'>Driving Assessment and\/or Vehicle Modifications<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='NDIS Access Report (to be submitted to the NDIA with an access request - this report is for individuals who are not yet participants of the NDIS'  id='choice_8_51_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_51_3' id='label_8_51_3' class='gform-field-label gform-field-label--type-inline'>NDIS Access Report (to be submitted to the NDIA with an access request - this report is for individuals who are not yet participants of the NDIS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_51_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Other'  id='choice_8_51_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_51_4' id='label_8_51_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_53'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_8_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_17'>Reason for Visit<\/label><div class='gfield_description' id='gfield_description_8_17'>Please state the main purpose of the referral\/reason for the appointment and\/or what the client is hoping to get out of the appointment(please also include ACAT docs if possible) If 4WW referral please include approx. height\/weight and whether it is for indoor or outdoor use:<\/div><div class='ginput_container ginput_container_text'><input name='input_17' id='input_8_17' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_17\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_11'>General Health<\/label><div class='gfield_description' id='gfield_description_8_11'>Please share any relevant medical history\/diagnosis (please include Mental Health history) that would be beneficial for the clinician to be aware of.<\/div><div class='ginput_container ginput_container_text'><input name='input_11' id='input_8_11' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_11\"    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_81' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_8_81' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_8_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_3' class='gform_page' data-js='page-field-id-81' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Home Safety Checklist<\/h3><\/div><fieldset id=\"field_8_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is there parking available on-site? Is the property visible from the street?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_82'>\n\t\t\t<div class='gchoice gchoice_8_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Yes'  id='choice_8_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_82_0' id='label_8_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_8_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_82_1' id='label_8_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_33'>Please provide further information<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_8_33' type='text' value='' class='large'    placeholder='Please provide further information'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is there phone reception on the property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_83'>\n\t\t\t<div class='gchoice gchoice_8_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_8_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_83_0' id='label_8_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_8_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_83_1' id='label_8_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are there any pets in the house?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_84'>\n\t\t\t<div class='gchoice gchoice_8_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_8_84_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_84\"   \/>\n\t\t\t\t\t<label for='choice_8_84_0' id='label_8_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_8_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_84_1' id='label_8_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_8_84'>It is requested that dogs \/ cats be put away during the clinicians visit<\/div><\/fieldset><fieldset id=\"field_8_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will anyone else be present during the appointment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_85'>\n\t\t\t<div class='gchoice gchoice_8_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Yes'  id='choice_8_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_85_0' id='label_8_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='No'  id='choice_8_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_85_1' id='label_8_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_54'>Name and Relationship to the Client<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_8_54' type='text' value='' class='large'    placeholder='Name and Relationship to the Client' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client a smoker?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_86'>\n\t\t\t<div class='gchoice gchoice_8_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_8_86_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_86\"   \/>\n\t\t\t\t\t<label for='choice_8_86_0' id='label_8_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_8_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_86_1' id='label_8_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_8_86'>Please kindly refrain from smoking during the home visit as it is part of workplace safety regulations. Any breaches will result in termination of the home visit, with applicable charges still applying<\/div><\/fieldset><fieldset id=\"field_8_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone on the property have a criminal history?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_87'>\n\t\t\t<div class='gchoice gchoice_8_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Yes'  id='choice_8_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_87_0' id='label_8_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_8_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_87_1' id='label_8_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_39'>Please provide details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_8_39' type='text' value='' class='large'    placeholder='Please provide details' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are there any firearms or weapons stored on the property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_88'>\n\t\t\t<div class='gchoice gchoice_8_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_8_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_88_0' id='label_8_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_8_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_88_1' id='label_8_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_55'>Please confirm they will be securely stored\/locked as per relevant laws.<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_8_55' type='text' value='' class='large'    placeholder='Please confirm they will be securely stored\/locked as per relevant laws.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_89\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone living in the house have a history of abuse, aggression, challenging behaviours, excessive drug\/alcohol use or violence that may impact work safety?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_89'>\n\t\t\t<div class='gchoice gchoice_8_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Yes'  id='choice_8_89_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_89_0' id='label_8_89_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='No'  id='choice_8_89_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_89_1' id='label_8_89_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_56'>Please Provide Details<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_8_56' type='text' value='' class='large'    placeholder='Please Provide Details'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone living in the house have an infectious disease (Eg. COVID, MRSA)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_90'>\n\t\t\t<div class='gchoice gchoice_8_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Yes'  id='choice_8_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_90_0' id='label_8_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='No'  id='choice_8_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_90_1' id='label_8_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_91\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_91'>Please Provide Details<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_8_91' type='text' value='' class='large'    placeholder='Please Provide Details'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_43'>Other Comments?<\/label><div class='gfield_description' id='gfield_description_8_43'>Is there anything else that the therapist needs\nto be aware of prior to attending the home visit?<\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_8_43' type='text' value='' class='medium'  aria-describedby=\"gfield_description_8_43\"    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_8_92' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_8_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_4' class='gform_page' data-js='page-field-id-92' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_93\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Form Completion<\/h3><\/div><div id=\"field_8_45\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_45'>How did you find out about us?<\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_8_45' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Case Manager' >Case Manager<\/option><option value='Word of Mouth' >Word of Mouth<\/option><option value='Google' >Google<\/option><option value='GP \/ Specialist' >GP \/ Specialist<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_8_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_57'>Please Provide Name<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_8_57' type='text' value='' class='medium'    placeholder='Please Provide Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_58'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_8_58' type='text' value='' class='large'    placeholder='Please Specify'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><\/div><div id=\"field_8_32\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_32'>FORM COMPLETED BY<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_8_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_75'>Your Email Address<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_8_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_77\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_8_77'>Please attach any relevant documentation<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_8_77' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_8_77&quot;,&quot;container&quot;:&quot;gform_multifile_upload_8_77&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_8_77&quot;,&quot;filelist&quot;:&quot;gform_preview_8_77&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/teamrehabsolutions.com.au\\\/staging\\\/?gf_page=90a5cb4e6b71fba&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/teamrehabsolutions.com.au\\\/staging\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/teamrehabsolutions.com.au\\\/staging\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:8,&quot;field_id&quot;:77,&quot;_gform_file_upload_nonce_8_77&quot;:&quot;880d89ee2c&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_8_77&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_8_77' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_8_77' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_8_77 gfield_description_8_77\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_8_77'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_8_77'><\/ul> <div id='gform_preview_8_77' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_8_77'>You may attach multiple files<\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_8' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_8' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <button type='button'  id='gform_save_8_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button><input type='hidden' name='gform_ajax' value='form_id=8&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=44a7d1bc3d43fb7c0f4232accaace4f0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_8' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_8' id='gform_theme_8' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_8' id='gform_style_settings_8' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_8' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='8' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_8' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_8' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='AUD' value='4i0UEUoyp6pUovFuFotuR9VYVLal8\/lSWxIbXC50W4\/ChXfYjsyVXZVFKjV40BQpnZINOJG1otuJ5ur4aUy05utAHXnI4NsTUuxuypnLAJhejrc=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_8' 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\/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_8' id='gform_target_page_number_8' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_8' id='gform_source_page_number_8' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_8' value='' \/>\n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_8' id='gform_ajax_frame_8' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 8, 'https:\/\/teamrehabsolutions.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_8').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_8');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_8').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_8').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_8').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_8').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_8').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_8').val();gformInitSpinner( 8, 'https:\/\/teamrehabsolutions.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [8, current_page]);window['gf_submitting_8'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_8').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_8').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [8]);window['gf_submitting_8'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_8').text());}else{jQuery('#gform_8').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"8\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_8\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_8\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_8\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            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data-element_type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-ce7d527 e-flex e-con-boxed e-con e-child\" data-id=\"ce7d527\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-014108b elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"014108b\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">PRIVATE PATIENT FORM<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-02f41e6 elementor-widget elementor-widget-shortcode\" data-id=\"02f41e6\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_11' style='display:none'><div id='gf_11' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11'  action='\/staging\/wp-json\/wp\/v2\/pages\/13#gf_11' data-formid='11' novalidate>\n        <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient\/Client Details<\/h3><\/div><fieldset id=\"field_11_21\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_11_21'>\n                            \n                            <span id='input_11_21_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_21.3' id='input_11_21_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_21_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_21_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_21.6' id='input_11_21_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_21_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_11_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Title<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_5'>\n\t\t\t<div class='gchoice gchoice_11_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Mr'  id='choice_11_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_5_0' id='label_11_5_0' class='gform-field-label gform-field-label--type-inline'>Mr<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Mrs'  id='choice_11_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_5_1' id='label_11_5_1' class='gform-field-label gform-field-label--type-inline'>Mrs<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Miss'  id='choice_11_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_5_2' id='label_11_5_2' class='gform-field-label gform-field-label--type-inline'>Miss<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Dr'  id='choice_11_5_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_5_3' id='label_11_5_3' class='gform-field-label gform-field-label--type-inline'>Dr<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_6\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_6'>Preferred Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_11_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_7'>Date of Birth:<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_11_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_8'>Mobile\/Home Phone Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_11_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Would the client like SMS reminders?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_9'>\n\t\t\t<div class='gchoice gchoice_11_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_11_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_9_0' id='label_11_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_11_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_9_1' id='label_11_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Aboriginal or Torres Straight Islander Origin?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_10'>\n\t\t\t<div class='gchoice gchoice_11_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Yes'  id='choice_11_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_10_0' id='label_11_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_11_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_10_1' id='label_11_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_11'>Clients General Practitioner:<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_11_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_12'>Medical Centre:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_11_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_13'>Client&#039;s Email Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_11_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_14'>Clients Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_11_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_23\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_23.1' id='input_11_23_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_11_23\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_11_23_1' >I agree to the below.<\/label><input type='hidden' name='input_23.2' value='I agree to the below.' class='gform_hidden' \/><input type='hidden' name='input_23.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_11_23' tabindex='0'>Client gives consent for treatment. Agrees to this consent remaining valid until such time as they withdraw consent. Also agrees and give consent for their case to be discussed with interested parties and communication with other<br \/>\ntreating medical professionals, for follow-up\/reminder calls, for discussion with third party insurers, disease notification as required by law, for use by all clinicians in this practice when consulting with you and for legal disclosure as<br \/>\nrequired by a court of law. A full National Privacy Policy is available for your perusal at www.privacy.gov.au. Client gives Team Rehab Solutions the right to send me occasional letters\/ emails \/ SMS promotional offers.<\/div><\/fieldset><div id=\"field_11_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_17'>Alternative contact to schedule appts (if different to client):<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_11_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_18'>Phone Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_11_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_11_77' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page' data-js='page-field-id-77' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Payment Details<\/h3><div class='gsection_description' id='gfield_description_11_31'>This field is required<\/div><\/div><fieldset id=\"field_11_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured\/Uninsured<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_28'><div class='gchoice gchoice_11_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='I am uninsured\/have private health insurance'  id='choice_11_28_1'   aria-describedby=\"gfield_description_11_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_28_1' id='label_11_28_1' class='gform-field-label gform-field-label--type-inline'>I am uninsured\/have private health insurance<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_11_28'>By ticking this box you understand full payment is required on day of appointment.<\/div><\/fieldset><fieldset id=\"field_11_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Private Health Insurer<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_30'>\n\t\t\t<div class='gchoice gchoice_11_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='BUPA'  id='choice_11_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_30_0' id='label_11_30_0' class='gform-field-label gform-field-label--type-inline'>BUPA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Medibank'  id='choice_11_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_30_1' id='label_11_30_1' class='gform-field-label gform-field-label--type-inline'>Medibank<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='AHM'  id='choice_11_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_30_2' id='label_11_30_2' class='gform-field-label gform-field-label--type-inline'>AHM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='HCF'  id='choice_11_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_30_3' id='label_11_30_3' class='gform-field-label gform-field-label--type-inline'>HCF<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='gf_other_choice'  id='choice_11_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_30_4' id='label_11_30_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_11_30_other' class='gchoice_other_control' name='input_30_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >EPC<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_33'><div class='gchoice gchoice_11_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='I have an Enhanced Primary Care Plan (EPC) referral from my GP'  id='choice_11_33_1'   aria-describedby=\"gfield_description_11_33\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_33_1' id='label_11_33_1' class='gform-field-label gform-field-label--type-inline'>I have an Enhanced Primary Care Plan (EPC) referral from my GP<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_11_33'>By ticking this box you understand that TRS is NOT a bulk billing company and that you will need to make full payment on the day of appointment.<\/div><\/fieldset><fieldset id=\"field_11_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Workcover Claim<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_32'><div class='gchoice gchoice_11_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Workcover Claim'  id='choice_11_32_1'   aria-describedby=\"gfield_description_11_32\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_32_1' id='label_11_32_1' class='gform-field-label gform-field-label--type-inline'>Workcover Claim<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_11_32'>By ticking this box you understand that there is a gap fee involved that you will need to pay on the day of appointment.<\/div><\/fieldset><div id=\"field_11_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_72'>Workcover Claim Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_11_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_73'>Workcover Case Manager Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_11_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_74'>Workcover Case Manager Email Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_11_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >DVA<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_34'><div class='gchoice gchoice_11_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='I am covered by Veteran&#039;s Affairs'  id='choice_11_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_34_1' id='label_11_34_1' class='gform-field-label gform-field-label--type-inline'>I am covered by Veteran's Affairs<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_71'>DVA Claim Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_11_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_35'>DVA File Number<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_11_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Card Type<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_37'><div class='gchoice gchoice_11_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Gold Card'  id='choice_11_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_37_1' id='label_11_37_1' class='gform-field-label gform-field-label--type-inline'>Gold Card<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='White Card'  id='choice_11_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_37_2' id='label_11_37_2' class='gform-field-label gform-field-label--type-inline'>White Card<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Gold Card TPI'  id='choice_11_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_37_3' id='label_11_37_3' class='gform-field-label gform-field-label--type-inline'>Gold Card TPI<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_36'>DVA Card Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_11_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_78' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_11_78' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_3' class='gform_page' data-js='page-field-id-78' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Services Required<\/h3><\/div><fieldset id=\"field_11_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Services Required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_40'><div class='gchoice gchoice_11_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Physiotherapy'  id='choice_11_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_1' id='label_11_40_1' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Exercise Physiology'  id='choice_11_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_2' id='label_11_40_2' class='gform-field-label gform-field-label--type-inline'>Exercise Physiology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Podiatry'  id='choice_11_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_3' id='label_11_40_3' class='gform-field-label gform-field-label--type-inline'>Podiatry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Dietitian'  id='choice_11_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_4' id='label_11_40_4' class='gform-field-label gform-field-label--type-inline'>Dietitian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.5' type='checkbox'  value='Remedial Massage'  id='choice_11_40_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_5' id='label_11_40_5' class='gform-field-label gform-field-label--type-inline'>Remedial Massage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.6' type='checkbox'  value='Occupational Therapy'  id='choice_11_40_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_6' id='label_11_40_6' class='gform-field-label gform-field-label--type-inline'>Occupational Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_42'>Reason for Visit:<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_11_42' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_42\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_11_42'>Please state the main purpose\/reason for the appointment.<\/div><\/div><div id=\"field_11_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_43'>General Health:<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_11_43' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_43\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_11_43'>Please share any relevant medical history\/diagnosis' (please include Mental Health history) that would be beneficial for the clinician to be aware of.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_79' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_11_79' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_4' class='gform_page' data-js='page-field-id-79' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Home Visit Safety Checklist:<\/h3><\/div><fieldset id=\"field_11_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is parking available on-site?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_45'>\n\t\t\t<div class='gchoice gchoice_11_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_11_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_45_0' id='label_11_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_11_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_45_1' id='label_11_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_49'>If no, please provide further information:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_11_49' type='text' value='' class='large'    placeholder='If no, please provide further information:'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is there phone reception on the property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_50'>\n\t\t\t<div class='gchoice gchoice_11_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Yes'  id='choice_11_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_50_0' id='label_11_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_11_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_50_1' id='label_11_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are there any pets in the house?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_51'>\n\t\t\t<div class='gchoice gchoice_11_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_11_51_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_11_51\"   \/>\n\t\t\t\t\t<label for='choice_11_51_0' id='label_11_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_11_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_51_1' id='label_11_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_11_51'>It is requested that dogs\/cats be put away during the clinicians visit.<\/div><\/fieldset><fieldset id=\"field_11_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will anyone else be present during the appointment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_52'>\n\t\t\t<div class='gchoice gchoice_11_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_11_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_52_0' id='label_11_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_11_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_52_1' id='label_11_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_53'>Name and Relationship to the Client<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_11_53' type='text' value='' class='large'    placeholder='Name and Relationship to the Client'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client a smoker?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_54'>\n\t\t\t<div class='gchoice gchoice_11_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_11_54_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_11_54\"   \/>\n\t\t\t\t\t<label for='choice_11_54_0' id='label_11_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_11_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_54_1' id='label_11_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_11_54'>Please kindly refrain from smoking during the home visit as it is part of workplace safety regulations. Any breaches will result\nin termination of the home visit, with applicable charges still applying.<\/div><\/fieldset><fieldset id=\"field_11_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone on the property have a criminal history?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_55'>\n\t\t\t<div class='gchoice gchoice_11_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_11_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_0' id='label_11_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_11_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_1' id='label_11_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_56'>If yes, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_11_56' type='text' value='' class='large'    placeholder='If yes, please specify.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are there any firearms or weapons stored on the property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_57'>\n\t\t\t<div class='gchoice gchoice_11_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_11_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_57_0' id='label_11_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_11_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_57_1' id='label_11_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_58'>If yes, please confirm they will be securely stored\/locked as per relevant laws.<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_11_58' type='text' value='' class='large'    placeholder='If yes, please confirm they will be securely stored\/locked as per relevant laws.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone living in the house have a history of abuse, aggression, challenging behaviours, excessive drug\/alcohol use or violence that may impact work safety?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_59'>\n\t\t\t<div class='gchoice gchoice_11_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_11_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_59_0' id='label_11_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_11_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_59_1' id='label_11_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_60'>If yes, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_11_60' type='text' value='' class='large'    placeholder='If yes, please specify.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does anyone living in the house have an infectious disease (Eg. COVID, MRSA)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_61'>\n\t\t\t<div class='gchoice gchoice_11_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_11_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_61_0' id='label_11_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_11_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_61_1' id='label_11_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_62'>If yes, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_11_62' type='text' value='' class='large'    placeholder='If yes, please specify.'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_63'>Other comments:<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_11_63' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_63\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_11_63'>Is there anything else that the therapist needs\nto be aware of prior to attending the home visit?<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_80' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_11_80' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_5' class='gform_page' data-js='page-field-id-80' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">How did you hear about us?<\/h3><\/div><fieldset id=\"field_11_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Source<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_65'>\n\t\t\t<div class='gchoice gchoice_11_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Google'  id='choice_11_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_65_0' id='label_11_65_0' class='gform-field-label gform-field-label--type-inline'>Google<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Word of mouth (please provide name)'  id='choice_11_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_65_1' id='label_11_65_1' class='gform-field-label gform-field-label--type-inline'>Word of mouth (please provide name)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='GP\/Specialist Referral (please provide name)'  id='choice_11_65_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_65_2' id='label_11_65_2' class='gform-field-label gform-field-label--type-inline'>GP\/Specialist Referral (please provide name)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_65_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Other (please provide details)'  id='choice_11_65_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_65_3' id='label_11_65_3' class='gform-field-label gform-field-label--type-inline'>Other (please provide details)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_66'>Referrer Details<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_11_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Completed By:<\/h3><\/div><div id=\"field_11_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_68'>Form Completed By:<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_11_68' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_68\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_11_68'>Name & Relationship (if not patient)<\/div><\/div><div id=\"field_11_70\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_70'>Date of Form Completion:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_70' id='input_11_70' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_11_70_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_11_70_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_11_70' class='gform_hidden' value='https:\/\/teamrehabsolutions.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_11_76\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_11_76'>Please attach any relevant documentation<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_11_76' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_11_76&quot;,&quot;container&quot;:&quot;gform_multifile_upload_11_76&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_11_76&quot;,&quot;filelist&quot;:&quot;gform_preview_11_76&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/teamrehabsolutions.com.au\\\/staging\\\/?gf_page=90a5cb4e6b71fba&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/teamrehabsolutions.com.au\\\/staging\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/teamrehabsolutions.com.au\\\/staging\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:11,&quot;field_id&quot;:76,&quot;_gform_file_upload_nonce_11_76&quot;:&quot;4c32918a46&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_11_76&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_11_76' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_11_76' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_11_76 gfield_description_11_76\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_11_76'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_11_76'><\/ul> <div id='gform_preview_11_76' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_11_76'>You may attach multiple files<\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_11' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_11' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=11&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=5a9417220df4f8cec38e5420316f8f96' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_11' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_11' id='gform_theme_11' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_11' id='gform_style_settings_11' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_11' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='11' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='AUD' value='3Wqb+46muxrwLmHL+UJ9nERQWCKCy77i4q2ysHJnL3kdW0eK4EmuxBgnWIGs83phdaRF7Rrlve0u4BoNLOXSQ1CduYf8zVUzeYy21yQoShHlQY0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_11' value='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' 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