{"id":869,"date":"2026-09-21T14:03:18","date_gmt":"2026-09-21T18:03:18","guid":{"rendered":"https:\/\/emocomp.com\/?page_id=869"},"modified":"2026-09-23T19:09:28","modified_gmt":"2026-09-23T23:09:28","slug":"referral","status":"publish","type":"page","link":"https:\/\/emocomp.com\/es\/referral\/","title":{"rendered":"Refer a Client"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"869\" class=\"elementor elementor-869\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a3f0ccd elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a3f0ccd\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-37dbc47\" data-id=\"37dbc47\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-b9d8436 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b9d8436\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-c1d56bf\" data-id=\"c1d56bf\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-bd80c0c elementor-widget__width-auto elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"bd80c0c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f9b0874 elementor-widget__width-auto elementor-widget elementor-widget-text-editor\" data-id=\"f9b0874\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tREFER A CLIENT\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<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<div class=\"elementor-element elementor-element-e0d3021 elementor-widget elementor-widget-heading\" data-id=\"e0d3021\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">A Partner in Your Client's Care<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-017a7b0 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"017a7b0\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-98b8367 elementor-hidden-tablet\" data-id=\"98b8367\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-24442cc elementor-widget elementor-widget-image\" data-id=\"24442cc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1826\" height=\"2560\" src=\"https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-scaled.jpg\" class=\"attachment-full size-full wp-image-215\" alt=\"\" srcset=\"https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-scaled.jpg 1826w, https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-214x300.jpg 214w, https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-730x1024.jpg 730w, https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-768x1077.jpg 768w, https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-1095x1536.jpg 1095w, https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-1461x2048.jpg 1461w\" sizes=\"(max-width: 1826px) 100vw, 1826px\" \/>\t\t\t\t\t\t\t\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<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-520b37e\" data-id=\"520b37e\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-cc94ffc elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"cc94ffc\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-a1dc938\" data-id=\"a1dc938\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-b4add86 elementor-widget__width-auto elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"b4add86\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cf71f6f elementor-widget__width-auto elementor-widget elementor-widget-text-editor\" data-id=\"cf71f6f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>For healthcare &amp; community providers<\/p>\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<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-4a60786 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4a60786\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-f282ae0\" data-id=\"f282ae0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-dbe5854 elementor-widget elementor-widget-heading\" data-id=\"dbe5854\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Refer a Client<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-eec8cc7 elementor-widget elementor-widget-text-editor\" data-id=\"eec8cc7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>Thank you for referring your client to Emotional Compass LLC.<\/strong><\/p><p>Use the form below to refer a client for outpatient therapy. The information you share helps our team review the referral, verify insurance, identify the right services, and match your client with a clinician who fits their needs and preferences.<\/p><p><em>This form is not for emergencies or situations that need immediate crisis intervention. If your client has an immediate safety concern, call <strong>911<\/strong> or have them call or text <strong>988<\/strong> (Suicide &amp; Crisis Lifeline).<\/em><\/p>\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<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1e18705 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1e18705\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2883dba\" data-id=\"2883dba\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-dd3bc8a elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"dd3bc8a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;,&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Provider Referral\" aria-label=\"Provider Referral\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"869\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"dd3bc8a\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Refer a Client | Emotional Compass\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"869\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_provider elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Provider\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-provider_name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFull Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[provider_name]\" id=\"form-field-provider_name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-provider_credentials elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_credentials\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCredentials \/ Title\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[provider_credentials]\" id=\"form-field-provider_credentials\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"e.g., MD, CNM, LCSW\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-provider_organization elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_organization\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOrganization \/ Practice Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[provider_organization]\" id=\"form-field-provider_organization\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-provider_phone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_phone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[provider_phone]\" id=\"form-field-provider_phone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-provider_email elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[provider_email]\" id=\"form-field-provider_email\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-provider_type elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_type\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProvider Type\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[provider_type]\" id=\"form-field-provider_type\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Primary Care Provider\">Primary Care Provider<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OB\/GYN\">OB\/GYN<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Midwife\">Midwife<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Doula\">Doula<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Therapist\/Counselor\">Therapist\/Counselor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Psychiatrist\/Psychologist\">Psychiatrist\/Psychologist<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Social Worker\">Social Worker<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hospital\/Healthcare Provider\">Hospital\/Healthcare Provider<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Case Manager\">Case Manager<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"School\/University Provider\">School\/University Provider<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Community Organization\">Community Organization<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-provider_contact_method elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_contact_method\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Contact Method\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Email\" id=\"form-field-provider_contact_method-0\" name=\"form_fields[provider_contact_method]\"> <label for=\"form-field-provider_contact_method-0\">Email<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Phone\" id=\"form-field-provider_contact_method-1\" name=\"form_fields[provider_contact_method]\"> <label for=\"form-field-provider_contact_method-1\">Phone<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Either\" id=\"form-field-provider_contact_method-2\" name=\"form_fields[provider_contact_method]\"> <label for=\"form-field-provider_contact_method-2\">Either<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-provider_wants_update elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-provider_wants_update\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWould you like an update on this referral?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-provider_wants_update-0\" name=\"form_fields[provider_wants_update]\"> <label for=\"form-field-provider_wants_update-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-provider_wants_update-1\" name=\"form_fields[provider_wants_update]\"> <label for=\"form-field-provider_wants_update-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_client elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Client\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-client_first_name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_first_name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[client_first_name]\" id=\"form-field-client_first_name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-client_last_name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_last_name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[client_last_name]\" id=\"form-field-client_last_name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-client_dob elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_dob\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[client_dob]\" id=\"form-field-client_dob\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-client_language elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_language\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Language\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[client_language]\" id=\"form-field-client_language\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"English\">English<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish\">Spanish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-client_language_other elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_language_other\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf other language, please specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[client_language_other]\" id=\"form-field-client_language_other\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-client_phone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_phone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[client_phone]\" id=\"form-field-client_phone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-client_email elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[client_email]\" id=\"form-field-client_email\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-client_address elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_address\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[client_address]\" id=\"form-field-client_address\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Street address, city, state, ZIP\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-client_aware elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_aware\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs the client aware of this referral to Emotional Compass?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-client_aware-0\" name=\"form_fields[client_aware]\" required=\"required\"> <label for=\"form-field-client_aware-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-client_aware-1\" name=\"form_fields[client_aware]\" required=\"required\"> <label for=\"form-field-client_aware-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-client_consent elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-client_consent\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHas the client given permission to share their information for this referral?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-client_consent-0\" name=\"form_fields[client_consent]\" required=\"required\"> <label for=\"form-field-client_consent-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-client_consent-1\" name=\"form_fields[client_consent]\" required=\"required\"> <label for=\"form-field-client_consent-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_insurance elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Insurance\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-insurance_use elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurance_use\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes the client plan to use insurance for therapy?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-insurance_use-0\" name=\"form_fields[insurance_use]\" required=\"required\"> <label for=\"form-field-insurance_use-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-insurance_use-1\" name=\"form_fields[insurance_use]\" required=\"required\"> <label for=\"form-field-insurance_use-1\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unsure\" id=\"form-field-insurance_use-2\" name=\"form_fields[insurance_use]\" required=\"required\"> <label for=\"form-field-insurance_use-2\">Unsure<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-insurance_primary_title elementor-col-100\">\n\t\t\t\t\t<h4 class=\"ec-form-subhead\">Primary Insurance<\/h4><p class=\"ec-form-note\">Complete this section if the client plans to use insurance.<\/p>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-primary_insurance_company elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_insurance_company\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Company\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[primary_insurance_company]\" id=\"form-field-primary_insurance_company\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-primary_member_id elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_member_id\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMember \/ Subscriber ID\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[primary_member_id]\" id=\"form-field-primary_member_id\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-primary_group_number elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_group_number\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGroup Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[primary_group_number]\" id=\"form-field-primary_group_number\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-primary_subscriber_name elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_subscriber_name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSubscriber Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[primary_subscriber_name]\" id=\"form-field-primary_subscriber_name\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-primary_subscriber_dob elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_subscriber_dob\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSubscriber Date of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[primary_subscriber_dob]\" id=\"form-field-primary_subscriber_dob\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-primary_subscriber_relationship elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_subscriber_relationship\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClient's Relationship to Subscriber\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[primary_subscriber_relationship]\" id=\"form-field-primary_subscriber_relationship\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Self\">Self<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Parent\">Parent<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spouse\">Spouse<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-primary_card_front elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_card_front\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Card (Front)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[primary_card_front]\" id=\"form-field-primary_card_front\" class=\"elementor-field elementor-size-md  elementor-upload-field\" data-maxsize=\"5\" data-maxsize-message=\"This file exceeds the maximum allowed size.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-primary_card_back elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-primary_card_back\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Card (Back)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[primary_card_back]\" id=\"form-field-primary_card_back\" class=\"elementor-field elementor-size-md  elementor-upload-field\" data-maxsize=\"5\" data-maxsize-message=\"This file exceeds the maximum allowed size.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-insurance_secondary_title elementor-col-100\">\n\t\t\t\t\t<h4 class=\"ec-form-subhead\">Secondary Insurance<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-secondary_insurance elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-secondary_insurance\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes the client have secondary insurance?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-secondary_insurance-0\" name=\"form_fields[secondary_insurance]\"> <label for=\"form-field-secondary_insurance-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-secondary_insurance-1\" name=\"form_fields[secondary_insurance]\"> <label for=\"form-field-secondary_insurance-1\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unsure\" id=\"form-field-secondary_insurance-2\" name=\"form_fields[secondary_insurance]\"> <label for=\"form-field-secondary_insurance-2\">Unsure<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-secondary_insurance_company elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-secondary_insurance_company\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Company\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[secondary_insurance_company]\" id=\"form-field-secondary_insurance_company\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-secondary_member_id elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-secondary_member_id\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMember \/ Subscriber ID\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[secondary_member_id]\" id=\"form-field-secondary_member_id\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-secondary_group_number elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-secondary_group_number\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGroup Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[secondary_group_number]\" id=\"form-field-secondary_group_number\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-secondary_card elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-secondary_card\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Card (Front & Back)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[secondary_card][]\" id=\"form-field-secondary_card\" class=\"elementor-field elementor-size-md  elementor-upload-field\" multiple=\"multiple\" data-maxsize=\"5\" data-maxsize-message=\"This file exceeds the maximum allowed size.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_referral elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Referral\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-referral_reasons elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-referral_reasons\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReason(s) for Referral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anxiety\" id=\"form-field-referral_reasons-0\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-0\">Anxiety<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Depression\" id=\"form-field-referral_reasons-1\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-1\">Depression<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Trauma\/PTSD\" id=\"form-field-referral_reasons-2\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-2\">Trauma\/PTSD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Perinatal\/Postpartum Mental Health\" id=\"form-field-referral_reasons-3\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-3\">Perinatal\/Postpartum Mental Health<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pregnancy After Loss\" id=\"form-field-referral_reasons-4\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-4\">Pregnancy After Loss<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pregnancy Loss\/Grief\" id=\"form-field-referral_reasons-5\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-5\">Pregnancy Loss\/Grief<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Infertility\/Fertility-Related Concerns\" id=\"form-field-referral_reasons-6\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-6\">Infertility\/Fertility-Related Concerns<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Perinatal OCD\" id=\"form-field-referral_reasons-7\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-7\">Perinatal OCD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Parenting\/Parent-Child Concerns\" id=\"form-field-referral_reasons-8\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-8\">Parenting\/Parent-Child Concerns<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Relationship\/Couples Concerns\" id=\"form-field-referral_reasons-9\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-9\">Relationship\/Couples Concerns<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Grief\/Loss\" id=\"form-field-referral_reasons-10\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-10\">Grief\/Loss<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Life Transition\" id=\"form-field-referral_reasons-11\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-11\">Life Transition<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stress\/Burnout\" id=\"form-field-referral_reasons-12\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-12\">Stress\/Burnout<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Self-Esteem\/Self-Worth\" id=\"form-field-referral_reasons-13\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-13\">Self-Esteem\/Self-Worth<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"EMDR\/Trauma Treatment\" id=\"form-field-referral_reasons-14\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-14\">EMDR\/Trauma Treatment<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-referral_reasons-15\" name=\"form_fields[referral_reasons][]\"> <label for=\"form-field-referral_reasons-15\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-referral_reason_other elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-referral_reason_other\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf other, please specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[referral_reason_other]\" id=\"form-field-referral_reason_other\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-presenting_concerns elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-presenting_concerns\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBriefly describe the reason for referral and the client's presenting concerns\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[presenting_concerns]\" id=\"form-field-presenting_concerns\" rows=\"5\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-clinical_title elementor-col-100\">\n\t\t\t\t\t<h4 class=\"ec-form-subhead\">Clinical Information<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-has_diagnosis elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-has_diagnosis\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes the client currently have a mental health diagnosis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-has_diagnosis-0\" name=\"form_fields[has_diagnosis]\"> <label for=\"form-field-has_diagnosis-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-has_diagnosis-1\" name=\"form_fields[has_diagnosis]\"> <label for=\"form-field-has_diagnosis-1\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unsure\" id=\"form-field-has_diagnosis-2\" name=\"form_fields[has_diagnosis]\"> <label for=\"form-field-has_diagnosis-2\">Unsure<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-diagnoses elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-diagnoses\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, please list the diagnosis\/diagnoses\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[diagnoses]\" id=\"form-field-diagnoses\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-on_medication elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-on_medication\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs the client currently prescribed psychiatric medication?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-on_medication-0\" name=\"form_fields[on_medication]\"> <label for=\"form-field-on_medication-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-on_medication-1\" name=\"form_fields[on_medication]\"> <label for=\"form-field-on_medication-1\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unknown\" id=\"form-field-on_medication-2\" name=\"form_fields[on_medication]\"> <label for=\"form-field-on_medication-2\">Unknown<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-medication_info elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medication_info\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf applicable, relevant medication information\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[medication_info]\" id=\"form-field-medication_info\" rows=\"3\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-clinical_documents elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-clinical_documents\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tScreenings or Clinical Documentation (optional, up to 3 files)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[clinical_documents][]\" id=\"form-field-clinical_documents\" class=\"elementor-field elementor-size-md  elementor-upload-field\" multiple=\"multiple\" data-maxsize=\"5\" data-maxsize-message=\"This file exceeds the maximum allowed size.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_safety elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Safety\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-safety_concerns elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-safety_concerns\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes the client have any current safety concerns?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No known safety concerns\" id=\"form-field-safety_concerns-0\" name=\"form_fields[safety_concerns]\" required=\"required\"> <label for=\"form-field-safety_concerns-0\">No known safety concerns<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-safety_concerns-1\" name=\"form_fields[safety_concerns]\" required=\"required\"> <label for=\"form-field-safety_concerns-1\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unsure\" id=\"form-field-safety_concerns-2\" name=\"form_fields[safety_concerns]\" required=\"required\"> <label for=\"form-field-safety_concerns-2\">Unsure<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-safety_concerns_details elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-safety_concerns_details\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes or unsure, please provide details\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[safety_concerns_details]\" id=\"form-field-safety_concerns_details\" rows=\"3\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-safety_history elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-safety_history\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs there a history of suicidal ideation, suicide attempts, self-harm, homicidal ideation, or other significant safety concerns the receiving clinician should be aware of?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-safety_history-0\" name=\"form_fields[safety_history]\"> <label for=\"form-field-safety_history-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-safety_history-1\" name=\"form_fields[safety_history]\"> <label for=\"form-field-safety_history-1\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unknown\" id=\"form-field-safety_history-2\" name=\"form_fields[safety_history]\"> <label for=\"form-field-safety_history-2\">Unknown<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-safety_history_details elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-safety_history_details\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, please provide details\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[safety_history_details]\" id=\"form-field-safety_history_details\" rows=\"3\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-higher_level_of_care elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-higher_level_of_care\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes the client currently require a level of care other than routine outpatient therapy?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-higher_level_of_care-0\" name=\"form_fields[higher_level_of_care]\" required=\"required\"> <label for=\"form-field-higher_level_of_care-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-higher_level_of_care-1\" name=\"form_fields[higher_level_of_care]\" required=\"required\"> <label for=\"form-field-higher_level_of_care-1\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unsure\" id=\"form-field-higher_level_of_care-2\" name=\"form_fields[higher_level_of_care]\" required=\"required\"> <label for=\"form-field-higher_level_of_care-2\">Unsure<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-level_of_care_note elementor-col-100\">\n\t\t\t\t\t<p class=\"ec-form-note\">If the client needs immediate evaluation, crisis intervention, hospitalization, or another higher level of care, please do not rely on this form as the only method of referral. For emergencies call <strong>911<\/strong>; for a mental health crisis call or text <strong>988<\/strong>.<\/p>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_preferences elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Preferences\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-therapy_type elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-therapy_type\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tType of Therapy Requested\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Individual Therapy\" id=\"form-field-therapy_type-0\" name=\"form_fields[therapy_type][]\"> <label for=\"form-field-therapy_type-0\">Individual Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Couples Therapy\" id=\"form-field-therapy_type-1\" name=\"form_fields[therapy_type][]\"> <label for=\"form-field-therapy_type-1\">Couples Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Family Therapy\" id=\"form-field-therapy_type-2\" name=\"form_fields[therapy_type][]\"> <label for=\"form-field-therapy_type-2\">Family Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Group Therapy\" id=\"form-field-therapy_type-3\" name=\"form_fields[therapy_type][]\"> <label for=\"form-field-therapy_type-3\">Group Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-therapy_type-4\" name=\"form_fields[therapy_type][]\"> <label for=\"form-field-therapy_type-4\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-clinician_preferences elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-clinician_preferences\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClinician Preferences (optional)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[clinician_preferences]\" id=\"form-field-clinician_preferences\" rows=\"3\" placeholder=\"e.g., language, gender, specialty, or other preferences\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-service_format elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-service_format\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Service Format\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Telehealth\" id=\"form-field-service_format-0\" name=\"form_fields[service_format]\" required=\"required\"> <label for=\"form-field-service_format-0\">Telehealth<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"In-person\" id=\"form-field-service_format-1\" name=\"form_fields[service_format]\" required=\"required\"> <label for=\"form-field-service_format-1\">In-person<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Either\" id=\"form-field-service_format-2\" name=\"form_fields[service_format]\" required=\"required\"> <label for=\"form-field-service_format-2\">Either<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-preferred_days elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-preferred_days\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Days\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Monday\" id=\"form-field-preferred_days-0\" name=\"form_fields[preferred_days][]\"> <label for=\"form-field-preferred_days-0\">Monday<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tuesday\" id=\"form-field-preferred_days-1\" name=\"form_fields[preferred_days][]\"> <label for=\"form-field-preferred_days-1\">Tuesday<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Wednesday\" id=\"form-field-preferred_days-2\" name=\"form_fields[preferred_days][]\"> <label for=\"form-field-preferred_days-2\">Wednesday<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Thursday\" id=\"form-field-preferred_days-3\" name=\"form_fields[preferred_days][]\"> <label for=\"form-field-preferred_days-3\">Thursday<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Friday\" id=\"form-field-preferred_days-4\" name=\"form_fields[preferred_days][]\"> <label for=\"form-field-preferred_days-4\">Friday<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No preference\" id=\"form-field-preferred_days-5\" name=\"form_fields[preferred_days][]\"> <label for=\"form-field-preferred_days-5\">No preference<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-preferred_times elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-preferred_times\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Time of Day\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Morning\" id=\"form-field-preferred_times-0\" name=\"form_fields[preferred_times][]\"> <label for=\"form-field-preferred_times-0\">Morning<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Afternoon\" id=\"form-field-preferred_times-1\" name=\"form_fields[preferred_times][]\"> <label for=\"form-field-preferred_times-1\">Afternoon<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Evening\" id=\"form-field-preferred_times-2\" name=\"form_fields[preferred_times][]\"> <label for=\"form-field-preferred_times-2\">Evening<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No preference\" id=\"form-field-preferred_times-3\" name=\"form_fields[preferred_times][]\"> <label for=\"form-field-preferred_times-3\">No preference<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-step_authorization elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Authorization\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-ack_title elementor-col-100\">\n\t\t\t\t\t<h4 class=\"ec-form-subhead\">Referral Acknowledgment<\/h4><p class=\"ec-form-note\">Please confirm each statement below.<\/p>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-ack_authorized elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[ack_authorized]\" id=\"form-field-ack_authorized\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-ack_authorized\">I am authorized to submit this referral and share the information included in this form.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-ack_client_aware elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[ack_client_aware]\" id=\"form-field-ack_client_aware\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-ack_client_aware\">The client is aware of this referral to Emotional Compass LLC, unless otherwise noted above.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-ack_accurate elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[ack_accurate]\" id=\"form-field-ack_accurate\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-ack_accurate\">The information provided is accurate to the best of my knowledge.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-ack_no_guarantee elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[ack_no_guarantee]\" id=\"form-field-ack_no_guarantee\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-ack_no_guarantee\">I understand that submitting this form does not guarantee acceptance for services or establish a therapist-client relationship.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-ack_contact elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[ack_contact]\" id=\"form-field-ack_contact\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-ack_contact\">I understand that Emotional Compass LLC may contact me for additional information about this referral.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-signature elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-signature\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tElectronic Signature\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[signature]\" id=\"form-field-signature\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Type your full name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-signature_date elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-signature_date\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[signature_date]\" id=\"form-field-signature_date\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text\">\n\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hp_field]\" id=\"form-field-hp_field\" class=\"elementor-field elementor-size-md \" style=\"display:none !important;\">\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-md\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit Referral<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2b37173 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2b37173\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-2a9f5ce\" data-id=\"2a9f5ce\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-5a0913c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5a0913c\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-b83c620\" data-id=\"b83c620\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-397a2ec elementor-widget__width-auto elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"397a2ec\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7bc19e5 elementor-widget__width-auto elementor-widget elementor-widget-text-editor\" data-id=\"7bc19e5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Not Sure Where to Start?<\/p>\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<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-dae3007 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"dae3007\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-af19452\" data-id=\"af19452\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7626f56 elementor-widget elementor-widget-text-editor\" data-id=\"7626f56\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Take a moment to explore our services. Whether you\u2019re looking for individual support, family counseling, or perinatal care\u2014we\u2019re here to help you find what fits best.<\/p>\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<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-340cc37\" data-id=\"340cc37\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-92c54f2 elementor-mobile-align-center elementor-widget elementor-widget-button\" data-id=\"92c54f2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/emocomp.com\/services\/\">\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\">See Our Services<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\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<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>CONTACT US We Are Happy To Help You We\u2019re here for you. Get In Touch Fill out the form below and we\u2019ll be in touch shortly. No content is added yet. Not Sure Where to Start? Take a moment to explore our services. Whether you\u2019re looking for individual support, family counseling, or perinatal care\u2014we\u2019re here [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-869","page","type-page","status-publish","hentry"],"translation":{"provider":"WPGlobus","version":"3.0.5","language":"es","enabled_languages":["en","es"],"languages":{"en":{"title":true,"content":true,"excerpt":false},"es":{"title":false,"content":false,"excerpt":false}}},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Refer a Client | Emotional Compass<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emocomp.com\/referral\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Refer a Client - Emotional Compass\" \/>\n<meta property=\"og:url\" content=\"https:\/\/emocomp.com\/referral\/\" \/>\n<meta property=\"og:site_name\" content=\"Emotional Compass\" \/>\n<meta property=\"article:modified_time\" content=\"2026-09-23T23:09:28+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/emocomp.com\/wp-content\/uploads\/2025\/04\/briana-tozour-hkkQbPa49UA-unsplash-scaled.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"1826\" \/>\n\t<meta property=\"og:image:height\" content=\"2560\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/emocomp.com\\\/referral\\\/\",\"url\":\"https:\\\/\\\/emocomp.com\\\/referral\\\/\",\"name\":\"Refer a Client | Emotional Compass\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/emocomp.com\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/emocomp.com\\\/referral\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/emocomp.com\\\/referral\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/emocomp.com\\\/wp-content\\\/uploads\\\/2025\\\/04\\\/briana-tozour-hkkQbPa49UA-unsplash-scaled.jpg\",\"datePublished\":\"2026-09-21T18:03:18+00:00\",\"dateModified\":\"2026-09-23T23:09:28+00:00\",\"description\":\"Refer a client to Emotional Compass LLC for outpatient therapy services. 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