{"id":22202,"date":"2022-06-14T09:52:52","date_gmt":"2022-06-14T13:52:52","guid":{"rendered":"https:\/\/theteamrecovery.org\/?page_id=22202"},"modified":"2023-04-27T10:38:44","modified_gmt":"2023-04-27T14:38:44","slug":"treatment-request","status":"publish","type":"page","link":"https:\/\/theteamrecovery.org\/treatment-request\/","title":{"rendered":"Treatment Request"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;2_5,3_5&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;2_5&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.17.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Treatment Request<\/h1>\n<p>Please fill out this form to quickly be contacted back for treatment services. Be sure to include as much information as possible.<\/p>\n<p>You can also call us directly at <a href=\"tel:1-419-561-5433\">419-561-LIFE (5433)<\/a>.<\/p>\n<p><strong>If this is an emergency, please call 911.<\/strong><\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code admin_label=&#8221;%91gravityforms id=%221%22%93&#8243; _builder_version=&#8221;4.20.4&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<script type=\"text\/javascript\">var 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class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/22202#gf_4' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_3\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_4_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_4\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_4\" ><label class='gfield_label gform-field-label' for='input_4_4'>Are you currently using drugs\/alcohol that might require detox?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_4_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Maybe' >Maybe<\/option><\/select><\/div><\/div><div id=\"field_4_5\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_5\" ><label class='gfield_label gform-field-label' for='input_4_5'>Are you currently clean\/sober, or already in treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_5'>Please explain in detail the length of sobriety, the agency in which you\u2019re receiving services, and level of care that you are currently in. <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_4_5' class='textarea small'  aria-describedby=\"gfield_description_4_5\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_7\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_7\" ><label class='gfield_label gform-field-label' for='input_4_7'>Do you have health insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_4_7' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/div><div id=\"field_4_8\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_8\" ><label class='gfield_label gform-field-label' for='input_4_8'>Please explain what kind of insurance you have<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_8'>For example- \u201cOhio Medicaid, CareSource\u201d<\/div><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_8\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_9\" ><label class='gfield_label gform-field-label' for='input_4_9'>Insurance Plan Number \/ Member ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_4_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_10\" 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gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_13\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_13\" ><label class='gfield_label gform-field-label' for='input_4_13'>Are you interested in sober living while attending treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_4_13' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Yes' 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Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_4_14' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_16\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_16\" ><label class='gfield_label gform-field-label' for='input_4_16'>How Did You Find Us<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_4_16' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Facebook' >Facebook<\/option><option value='Google' >Google<\/option><option value='Instagram' >Instagram<\/option><option value='Twitter' >Twitter<\/option><option value='TikTok' >TikTok<\/option><option value='Personal Referral' >Personal Referral<\/option><option value='TR Staff Referral' >TR Staff Referral<\/option><option value='Agency Referral' >Agency Referral<\/option><option value='Probation' >Probation<\/option><option value='Court' >Court<\/option><option value='Healthcare' >Healthcare<\/option><option value='Other (please specify)' >Other (please specify)<\/option><\/select><\/div><\/div><div id=\"field_4_17\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_17\" ><label class='gfield_label gform-field-label' for='input_4_17'>Please Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_4_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_15\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_15\" ><label class='gfield_label gform-field-label' for='input_4_15'>Is there anything else that you\u2019d like us to know?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_4_15' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_4\"]){return false;}  if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  jQuery(\"#gform_4\").trigger(\"submit\",[true]); 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Be sure to include as much information as possible. You can also call us directly at 419-561-LIFE (5433). If this is an emergency, please call 911.\n                <div class='gf_browser_safari gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='1' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/22202#gf_4' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_3\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_4_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_4\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_4\" ><label class='gfield_label gform-field-label' for='input_4_4'>Are you currently using drugs\/alcohol that might require detox?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_4_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Maybe' >Maybe<\/option><\/select><\/div><\/div><div id=\"field_4_5\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_5\" ><label class='gfield_label gform-field-label' for='input_4_5'>Are you currently clean\/sober, or already in treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_5'>Please explain in detail the length of sobriety, the agency in which you\u2019re receiving services, and level of care that you are currently in. <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_4_5' class='textarea small'  aria-describedby=\"gfield_description_4_5\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_7\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_7\" ><label class='gfield_label gform-field-label' for='input_4_7'>Do you have health insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_4_7' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/div><div id=\"field_4_8\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_8\" ><label class='gfield_label gform-field-label' for='input_4_8'>Please explain what kind of insurance you have<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_8'>For example- \u201cOhio Medicaid, CareSource\u201d<\/div><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_8\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_9\" ><label class='gfield_label gform-field-label' for='input_4_9'>Insurance Plan Number \/ Member ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_4_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_10\" class=\"gfield gfield--type-fileupload gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_10\" ><label class='gfield_label gform-field-label' for='input_4_10'>Upload a photo of your insurance card<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='3145728' \/><input name='input_10' id='input_4_10' type='file' class='large' aria-describedby=\"gfield_upload_rules_4_10\" onchange='javascript:gformValidateFileSize( this, 3145728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_10'>Accepted file types: jpg, png, pdf, Max. file size: 3 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_10'><\/div><\/div><\/div><div id=\"field_4_11\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_11\" ><label class='gfield_label gform-field-label' for='input_4_11'>Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_4_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_12\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_12\" ><label class='gfield_label gform-field-label' for='input_4_12'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_13\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_13\" ><label class='gfield_label gform-field-label' for='input_4_13'>Are you interested in sober living while attending treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_4_13' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Maybe' >Maybe<\/option><\/select><\/div><\/div><div id=\"field_4_14\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_14\" ><label class='gfield_label gform-field-label' for='input_4_14'>When are you ready to come into treatment with us? Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_4_14' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_16\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_16\" ><label class='gfield_label gform-field-label' for='input_4_16'>How Did You Find Us<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_4_16' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'>Select One<\/option><option value='Facebook' >Facebook<\/option><option value='Google' >Google<\/option><option value='Instagram' >Instagram<\/option><option value='Twitter' >Twitter<\/option><option value='TikTok' >TikTok<\/option><option value='Personal Referral' >Personal Referral<\/option><option value='TR Staff Referral' >TR Staff Referral<\/option><option value='Agency Referral' >Agency Referral<\/option><option value='Probation' >Probation<\/option><option value='Court' >Court<\/option><option value='Healthcare' >Healthcare<\/option><option value='Other (please specify)' >Other (please specify)<\/option><\/select><\/div><\/div><div id=\"field_4_17\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_17\" ><label class='gfield_label gform-field-label' for='input_4_17'>Please Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_4_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_15\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_15\" ><label class='gfield_label gform-field-label' for='input_4_15'>Is there anything else that you\u2019d like us to know?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_4_15' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_4\"]){return false;}  if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  jQuery(\"#gform_4\").trigger(\"submit\",[true]); 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