{"id":138,"date":"2025-09-02T19:33:28","date_gmt":"2025-09-02T09:33:28","guid":{"rendered":"https:\/\/maiyouthclub.com\/disability-services\/?page_id=138"},"modified":"2025-09-02T19:36:50","modified_gmt":"2025-09-02T09:36:50","slug":"referral","status":"publish","type":"page","link":"https:\/\/maiyouthclub.com\/disability-services\/referral\/","title":{"rendered":"Referral"},"content":{"rendered":"<div class=\"container\">\n<div class=\"row justify-content-center\">\n<div class=\"col-lg-8\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f141-o1\" lang=\"en-AU\" dir=\"ltr\" data-wpcf7-id=\"141\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/disability-services\/wp-json\/wp\/v2\/pages\/138#wpcf7-f141-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"141\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_AU\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f141-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"ref_form_box ref_box_pink\">\n\t<div class=\"ref_form_box_heading\">\n\t\t<p>Ready To <strong>Get Started?<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>I am completing this for\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"completing\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"completing\"><option value=\"\">Please Select<\/option><option value=\"Myself as the participant\">Myself as the participant<\/option><option value=\"Someone I am referring to Mai Youth Club\">Someone I am referring to Mai Youth Club<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box ref_box_green\">\n\t<div class=\"ref_form_box_heading\">\n\t\t<p>Participant <strong>Details<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>First Name\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-first-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Last Name\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-last-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Date of Birth\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Gender\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"gender\"><option value=\"\">Please Select<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Prefer not to say\">Prefer not to say<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Home Address\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant Phone Number\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant Email Address\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant NDIS Number\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ndis-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ndis-number\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Does The Participant Have A Legal Guardian \/ Nominee?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_radio\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"legal-guardian\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"legal-guardian\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"legal-guardian\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box ref_box_blue\">\n\t<div class=\"ref_form_box_heading\">\n\t\t<p>Cultural <strong>Details<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant Country Of Birth\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"birth-country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"birth-country\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Does The Participant Require An Interpreter?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"interpreter\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"interpreter\"><option value=\"\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Relevant Culture Or Religious Considerations(If Any)?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"religious-considerations\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"religious-considerations\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Does The Listed Participant Identify As An Aboriginal Or Torres Strait Islander?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"torres-strait\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"torres-strait\"><option value=\"\">Please Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box ref_box_red\">\n\t<div class=\"ref_form_box_heading\">\n\t\t<p>Services <strong>Request<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Type Of Primary Service Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"primary-service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"primary-service\"><option value=\"\">Select Service<\/option><option value=\"Assistance To Access And Maintain Employment\">Assistance To Access And Maintain Employment<\/option><option value=\"Assistive Product For Personal Care And Safety\">Assistive Product For Personal Care And Safety<\/option><option value=\"Assistance With Daily Personal Activities (High Intensity)\">Assistance With Daily Personal Activities (High Intensity)<\/option><option value=\"Personal Mobility Equipment\">Personal Mobility Equipment<\/option><option value=\"Assistance With Life Transition\">Assistance With Life Transition<\/option><option value=\"Assistance With Daily Personal Activities\">Assistance With Daily Personal Activities<\/option><option value=\"Assistance With Travel And Transport\">Assistance With Travel And Transport<\/option><option value=\"Specialised Positive Behaviour Support Implementation\">Specialised Positive Behaviour Support Implementation<\/option><option value=\"Home Modifications\">Home Modifications<\/option><option value=\"Assistive Equipment For Recreation\">Assistive Equipment For Recreation<\/option><option value=\"Assistance With Daily Tasks\/shared Living\">Assistance With Daily Tasks\/shared Living<\/option><option value=\"Innovative Community Participation\">Innovative Community Participation<\/option><option value=\"Development Of Life Skills\">Development Of Life Skills<\/option><option value=\"Assistance With Household Tasks\">Assistance With Household Tasks<\/option><option value=\"Assistive Products For Household Tasks\">Assistive Products For Household Tasks<\/option><option value=\"Participation In The Community\">Participation In The Community<\/option><option value=\"Assistance Animals\">Assistance Animals<\/option><option value=\"Specialist Disability Accommodation (SDA)\">Specialist Disability Accommodation (SDA)<\/option><option value=\"Specialised Supported Employment\">Specialised Supported Employment<\/option><option value=\"Group And Centre-Based Activities\">Group And Centre-Based Activities<\/option><option value=\"Vision Equipment\">Vision Equipment<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Number Of Hours Requested For Service:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"service-hour\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"service-hour\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Type Of Secondary Service Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"secondary-service\"><option value=\"\">Select Service<\/option><option value=\"Assistance To Access And Maintain Employment\">Assistance To Access And Maintain Employment<\/option><option value=\"Assistive Product For Personal Care And Safety\">Assistive Product For Personal Care And Safety<\/option><option value=\"Assistance With Daily Personal Activities (High Intensity)\">Assistance With Daily Personal Activities (High Intensity)<\/option><option value=\"Personal Mobility Equipment\">Personal Mobility Equipment<\/option><option value=\"Assistance With Life Transition\">Assistance With Life Transition<\/option><option value=\"Assistance With Daily Personal Activities\">Assistance With Daily Personal Activities<\/option><option value=\"Assistance With Travel And Transport\">Assistance With Travel And Transport<\/option><option value=\"Specialised Positive Behaviour Support Implementation\">Specialised Positive Behaviour Support Implementation<\/option><option value=\"Home Modifications\">Home Modifications<\/option><option value=\"Assistive Equipment For Recreation\">Assistive Equipment For Recreation<\/option><option value=\"Assistance With Daily Tasks\/shared Living\">Assistance With Daily Tasks\/shared Living<\/option><option value=\"Innovative Community Participation\">Innovative Community Participation<\/option><option value=\"Development Of Life Skills\">Development Of Life Skills<\/option><option value=\"Assistance With Household Tasks\">Assistance With Household Tasks<\/option><option value=\"Assistive Products For Household Tasks\">Assistive Products For Household Tasks<\/option><option value=\"Participation In The Community\">Participation In The Community<\/option><option value=\"Assistance Animals\">Assistance Animals<\/option><option value=\"Specialist Disability Accommodation (SDA)\">Specialist Disability Accommodation (SDA)<\/option><option value=\"Specialised Supported Employment\">Specialised Supported Employment<\/option><option value=\"Group And Centre-Based Activities\">Group And Centre-Based Activities<\/option><option value=\"Vision Equipment\">Vision Equipment<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Additional Service Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"additional-service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"additional-service\"><option value=\"\">Select Service<\/option><option value=\"Assistance To Access And Maintain Employment\">Assistance To Access And Maintain Employment<\/option><option value=\"Assistive Product For Personal Care And Safety\">Assistive Product For Personal Care And Safety<\/option><option value=\"Assistance With Daily Personal Activities (High Intensity)\">Assistance With Daily Personal Activities (High Intensity)<\/option><option value=\"Personal Mobility Equipment\">Personal Mobility Equipment<\/option><option value=\"Assistance With Life Transition\">Assistance With Life Transition<\/option><option value=\"Assistance With Daily Personal Activities\">Assistance With Daily Personal Activities<\/option><option value=\"Assistance With Travel And Transport\">Assistance With Travel And Transport<\/option><option value=\"Specialised Positive Behaviour Support Implementation\">Specialised Positive Behaviour Support Implementation<\/option><option value=\"Home Modifications\">Home Modifications<\/option><option value=\"Assistive Equipment For Recreation\">Assistive Equipment For Recreation<\/option><option value=\"Assistance With Daily Tasks\/shared Living\">Assistance With Daily Tasks\/shared Living<\/option><option value=\"Innovative Community Participation\">Innovative Community Participation<\/option><option value=\"Development Of Life Skills\">Development Of Life Skills<\/option><option value=\"Assistance With Household Tasks\">Assistance With Household Tasks<\/option><option value=\"Assistive Products For Household Tasks\">Assistive Products For Household Tasks<\/option><option value=\"Participation In The Community\">Participation In The Community<\/option><option value=\"Assistance Animals\">Assistance Animals<\/option><option value=\"Specialist Disability Accommodation (SDA)\">Specialist Disability Accommodation (SDA)<\/option><option value=\"Specialised Supported Employment\">Specialised Supported Employment<\/option><option value=\"Group And Centre-Based Activities\">Group And Centre-Based Activities<\/option><option value=\"Vision Equipment\">Vision Equipment<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant's Relevant Conditions \/ Disability (Please List):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"relevant-conditions\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"relevant-conditions\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Extra Information That May Assist With Preparation For Initial Appointment:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"extra-information\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"extra-information\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Special Assessments Or Therapies Required:\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"special-assessments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"special-assessments\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Notes For Practitioners (Additional Relevant Details):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"relevant-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"relevant-details\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box ref_box_green\">\n\t<div class=\"ref_form_box_heading\">\n\t\t<p>Booking <strong>Details<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Preferred Consultation Type(s):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_radio\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consultation-type\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"In Clinic\" \/><span class=\"wpcf7-list-item-label\">In Clinic<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"In Home Service\" \/><span class=\"wpcf7-list-item-label\">In Home Service<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"Telehealth\" \/><span class=\"wpcf7-list-item-label\">Telehealth<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"consultation-type[]\" value=\"Community\" \/><span class=\"wpcf7-list-item-label\">Community<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-6 col-md-6\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Who Should We Contact To Make An Appointment?\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact-appointment\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"contact-appointment\"><option value=\"\">Please Select<\/option><option value=\"Participant\/ Nominee\">Participant\/ Nominee<\/option><option value=\"Support Coordinator\">Support Coordinator<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Notes For Reception Staff (If Applicable):\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reception-staff\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"reception-staff\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"ref_form_box ref_box_blue\">\n\t<div class=\"ref_form_box_heading\">\n\t\t<p>NDIS <strong>Information<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\">\n\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t<div class=\"ref_form_box_label\">\n\t\t\t\t<p>Participant\u2019s NDIS Plan Type\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"ref_form_box_input\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ndis-plan-type\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"ndis-plan-type\"><option value=\"\">Please Select<\/option><option value=\"NDIA Managed\">NDIA Managed<\/option><option value=\"Plan Managed\">Plan Managed<\/option><option value=\"Self\/ Nominee-Managed\">Self\/ Nominee-Managed<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-lg-12 col-md-12 contact_btn\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/full-width.php","meta":{"footnotes":""},"class_list":["post-138","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/pages\/138","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/comments?post=138"}],"version-history":[{"count":3,"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/pages\/138\/revisions"}],"predecessor-version":[{"id":142,"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/pages\/138\/revisions\/142"}],"wp:attachment":[{"href":"https:\/\/maiyouthclub.com\/disability-services\/wp-json\/wp\/v2\/media?parent=138"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}