{"id":938,"date":"2023-09-21T22:56:14","date_gmt":"2023-09-21T22:56:14","guid":{"rendered":"http:\/\/embtherapy.net\/clone\/?page_id=938"},"modified":"2025-07-06T06:10:50","modified_gmt":"2025-07-06T06:10:50","slug":"intake-enquiry-form","status":"publish","type":"page","link":"https:\/\/embtherapy.net\/clone\/intake-enquiry-form\/","title":{"rendered":"Intake Enquiry Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"938\" class=\"elementor elementor-938\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2a2add2 e-flex e-con-boxed e-con e-parent\" data-id=\"2a2add2\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5bad932 elementor-widget elementor-widget-heading\" data-id=\"5bad932\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Intake Enquiry Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-31c308c elementor-widget elementor-widget-heading\" data-id=\"31c308c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Please call or text 562-263-6041<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-adc1445 e-flex e-con-boxed e-con e-parent\" data-id=\"adc1445\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f29e25b elementor-widget elementor-widget-heading\" data-id=\"f29e25b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">We would want your enquiry process to be as smooth and efficient as possible. Please complete this form so we can direct you to a clinician that will best fit your needs.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-fe36c8e e-flex e-con-boxed e-con e-parent\" data-id=\"fe36c8e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a58c763 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"a58c763\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Appointment\" aria-label=\"Appointment\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"938\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"a58c763\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Intake Enquiry Form\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"938\"\/>\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-date elementor-field-group elementor-column elementor-field-group-field_64a5861 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-field_64a5861\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t When would you like to start therapy?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_64a5861]\" id=\"form-field-field_64a5861\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"DD-MM-YY\" 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 elementor-field-group elementor-column elementor-field-group-field_f268cb8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f268cb8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease provide preferable day and time of the week that works best for you on a recurring basis.\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[field_f268cb8]\" id=\"form-field-field_f268cb8\" 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-field_9159000 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-field_9159000\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAppointment Type: \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 Appointment\" id=\"form-field-field_9159000-0\" name=\"form_fields[field_9159000]\" required=\"required\"> <label for=\"form-field-field_9159000-0\">TeleHealth Appointment<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"In Person Appointment\" id=\"form-field-field_9159000-1\" name=\"form_fields[field_9159000]\" required=\"required\"> <label for=\"form-field-field_9159000-1\">In Person Appointment<\/label><\/span><\/div>\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-field_9b756c6 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-field_9b756c6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease select your insurance plan:\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[field_9b756c6]\" id=\"form-field-field_9b756c6\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Aetna\">Aetna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Optum\">Optum<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United\">United<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cigna\">Cigna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Carelon\">Carelon<\/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-field_a77832d 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-field_a77832d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMember 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[field_a77832d]\" id=\"form-field-field_a77832d\" 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-field_ebdab1a 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-field_ebdab1a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t Group 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[field_ebdab1a]\" id=\"form-field-field_ebdab1a\" 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-field_d419f93 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-field_d419f93\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you the primary subscriber? If no, 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[field_d419f93]\" id=\"form-field-field_d419f93\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"I am the primary subscriber\">I am the primary subscriber<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Child \">Child <\/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-text elementor-field-group elementor-column elementor-field-group-field_cddd97e 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-field_cddd97e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t Primary 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[field_cddd97e]\" id=\"form-field-field_cddd97e\" 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-field_9a2f23e 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-field_9a2f23e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t Primary Subscriber's 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[field_9a2f23e]\" id=\"form-field-field_9a2f23e\" 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 elementor-field-group elementor-column elementor-field-group-field_f939698 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-field_f939698\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZip code listed with insurance 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[field_f939698]\" id=\"form-field-field_f939698\" 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-field_4d2ef45 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4d2ef45\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t Are you seeking a specific modality of treatment? If so, please select:\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[field_4d2ef45]\" id=\"form-field-field_4d2ef45\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"Cognitive Behavioral Therapy\">Cognitive Behavioral Therapy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Internal Family Systems\">Internal Family Systems<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"EMDR\">EMDR<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dialectical Behavioral Therapy\">Dialectical Behavioral Therapy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Solution Focused Therapy\">Solution Focused Therapy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Supportive counseling\">Supportive counseling<\/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-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-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYour 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[name]\" id=\"form-field-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-field_5b01277 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-field_5b01277\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYour DOB\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_5b01277]\" id=\"form-field-field_5b01277\" 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-email elementor-field-group elementor-column elementor-field-group-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-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\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[email]\" id=\"form-field-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-tel elementor-field-group elementor-column elementor-field-group-field_8f1bf95 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-field_8f1bf95\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone \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[field_8f1bf95]\" id=\"form-field-field_8f1bf95\" 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-html elementor-field-group elementor-column elementor-field-group-field_e84a359 elementor-col-100\">\n\t\t\t\t\tAt this time our group practice does not offer psychiatry, medication management, one-time evaluations or crisis services. If you are in crisis, please go to your nearest ER or call 1-800-273-8255\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\">Send<\/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\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Intake Enquiry Form Please call or text 562-263-6041 We would want your enquiry process to be as smooth and efficient as possible. Please complete this form so we can direct you to a clinician that will best fit your needs.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-938","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/pages\/938","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/comments?post=938"}],"version-history":[{"count":24,"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/pages\/938\/revisions"}],"predecessor-version":[{"id":2966,"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/pages\/938\/revisions\/2966"}],"wp:attachment":[{"href":"https:\/\/embtherapy.net\/clone\/wp-json\/wp\/v2\/media?parent=938"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}