{"id":2,"date":"2019-04-08T17:55:51","date_gmt":"2019-04-08T17:55:51","guid":{"rendered":"http:\/\/www.adhdtx.pcaconsulting.net\/?page_id=2"},"modified":"2019-04-10T01:03:19","modified_gmt":"2019-04-10T01:03:19","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/pcasecure.com\/adultatt\/","title":{"rendered":"Request an Appointment"},"content":{"rendered":"<p class=\"oneColElsCtr\"><span class=\"body\">For an Evaluation or For Behavioral Therapy<\/span><\/p>\n<p><span class=\"body\"><i>Note:<\/i>\u00a0All information received from this site is held in a secure server and kept confidential. 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return false;\">    <input type=\"hidden\" id=\"counter7\" value=\"54\" name=\"counter7\" \/>    <input type=\"hidden\" id=\"Itemid7\" value=\"\" name=\"Itemid7\" \/><div class=\"wdform-page-and-images\" style=\"display:table; border-top:0px solid black;\"><div id=\"7form_view1\" class=\"wdform_page\" page_title=\"Untitled page\" next_title=\"Next\" next_type=\"text\" next_class=\"wdform-page-button\" next_checkable=\"false\" previous_title=\"Previous\" previous_type=\"text\" previous_class=\"wdform-page-button\" previous_checkable=\"false\"><div class=\"wdform_section\"><div class=\"wdform_column ui-sortable\"><div wdid=\"1\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_editor\" class=\"wdform-field\"><h3 style=\"color: #f2773e;\">General Information<\/h3><div style=\"min-width: 300px; border-top:1px solid\"><\/div><\/div><\/div><div wdid=\"2\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Patient Name:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_2_element7\" name=\"wdform_2_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"3\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Parent\/Guardian Name (if applicable):<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_3_element7\" name=\"wdform_3_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"6\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_address\" class=\"wdform-field\"  style=\"width:600px\"><div class=\"wdform-label-section\" style=\"float: left;; width: 300px;\"><span class=\"wdform-label\">Home Address:<\/span><\/div><div class=\"wdform-element-section wdform_address\" style=\" width: 300px;\"><div>            <span style=\"float: left; width: 100%; padding-bottom: 8px; display: block;\"><input type=\"text\" id=\"wdform_6_street17\" name=\"wdform_6_street17\" value=\"\" style=\"width: 100%;\" ><label class=\"mini_label\" >Street Address<\/label><\/span><span style=\"float: left; width: 48%; padding-bottom: 8px;\"><input type=\"text\" id=\"wdform_6_city7\" name=\"wdform_8_city7\" value=\"\" style=\"width: 100%;\" ><label class=\"mini_label\" >City<\/label><\/span><span style=\"float: right; width: 48%; padding-bottom: 8px;\"><input type=\"text\" id=\"wdform_6_state7\" name=\"wdform_9_state7\" value=\"\" style=\"width: 100%;\" ><label class=\"mini_label\">State<\/label><\/span><span style=\"float: left; width: 48%; padding-bottom: 8px;\"><input type=\"text\" id=\"wdform_6_postal7\" name=\"wdform_10_postal7\" value=\"\" style=\"width: 100%;\" ><label class=\"mini_label\">Zip Code<\/label><\/span><\/div><div style=\"clear:both;\"><\/div><\/div><\/div><\/div><div wdid=\"12\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Home Phone:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_12_element7\" name=\"wdform_12_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"13\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Work Phone:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_13_element7\" name=\"wdform_13_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"14\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Cell Phone:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_14_element7\" name=\"wdform_14_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"15\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_submitter_mail\" class=\"wdform-field\"  style=\"width:500px\"><div class=\"wdform-label-section\" style=\"float: left;; width: 300px;\"><span class=\"wdform-label\">Email:<\/span><\/div><div class=\"wdform-element-section \" style=\" width: 200px;\"><input type=\"text\" class=\"input_deactive\" id=\"wdform_15_element7\" name=\"wdform_15_element7\" value=\"\" title=\"\"  style=\"width: 100%;\"  onchange=\"wd_check_email('15', '7', 'This is not a valid email address.', 'The email addresses don\\'t match')\"><\/div><\/div><\/div><div wdid=\"16\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Date of Birth:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_16_element7\" name=\"wdform_16_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"17\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">SSN:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_17_element7\" name=\"wdform_17_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"18\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Age:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_18_element7\" name=\"wdform_18_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"19\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"float: left;; width: 300px;\"><span class=\"wdform-label\">Marital Status:<\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: inline-block; vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_19_element70\" name=\"wdform_19_element7\" value=\"Married\" onclick=\"set_default(&quot;wdform_19&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_19_element70\"><span><\/span>Married<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_19_element71\" name=\"wdform_19_element7\" value=\"Single\" onclick=\"set_default(&quot;wdform_19&quot;,&quot;1&quot;,&quot;7&quot;); \"  ><label for=\"wdform_19_element71\"><span><\/span>Single<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_19_element72\" name=\"wdform_19_element7\" value=\"Divorced\" onclick=\"set_default(&quot;wdform_19&quot;,&quot;2&quot;,&quot;7&quot;); \"  ><label for=\"wdform_19_element72\"><span><\/span>Divorced<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"20\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"float: left;; width: 300px;\"><span class=\"wdform-label\">Sex:<\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: inline-block; vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_20_element70\" name=\"wdform_20_element7\" value=\"Male\" onclick=\"set_default(&quot;wdform_20&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_20_element70\"><span><\/span>Male<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_20_element71\" name=\"wdform_20_element7\" value=\"Female\" onclick=\"set_default(&quot;wdform_20&quot;,&quot;1&quot;,&quot;7&quot;); \"  ><label for=\"wdform_20_element71\"><span><\/span>Female<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"21\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Employer:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_21_element7\" name=\"wdform_21_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"22\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Occupation:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_22_element7\" name=\"wdform_22_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"24\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_editor\" class=\"wdform-field\"><h3 style=\"color: #f2773e;\">Insurance Information<\/h3><div style=\"min-width: 300px; border-top:1px solid\"><\/div><\/div><\/div><div wdid=\"27\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"float: left;; width: 300px;\"><span class=\"wdform-label\">Self Pay:<\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: inline-block; vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_27_element70\" name=\"wdform_27_element7\" value=\"Yes\" onclick=\"set_default(&quot;wdform_27&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_27_element70\"><span><\/span>Yes<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_27_element71\" name=\"wdform_27_element7\" value=\"No\" onclick=\"set_default(&quot;wdform_27&quot;,&quot;1&quot;,&quot;7&quot;); \"  ><label for=\"wdform_27_element71\"><span><\/span>No<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"28\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"float: left;; width: 300px;\"><span class=\"wdform-label\">Insurance:<\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: inline-block; vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_28_element70\" name=\"wdform_28_element7\" value=\"Yes\" onclick=\"set_default(&quot;wdform_28&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_28_element70\"><span><\/span>Yes<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_28_element71\" name=\"wdform_28_element7\" value=\"No\" onclick=\"set_default(&quot;wdform_28&quot;,&quot;1&quot;,&quot;7&quot;); \"  ><label for=\"wdform_28_element71\"><span><\/span>No<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"29\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_editor\" class=\"wdform-field\">If using insurance, please fill out the information below:<\/div><\/div><div wdid=\"30\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Insurance Company:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_30_element7\" name=\"wdform_30_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"31\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Policy Number:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_31_element7\" name=\"wdform_31_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"32\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Group Number:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_32_element7\" name=\"wdform_32_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"33\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:750px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Phone Number:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:400px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_33_element7\" name=\"wdform_33_element7\" value=\"(Mental or Behavioral Health Benefits\/Eligibility)\" title=\"(Mental or Behavioral Health Benefits\/Eligibility)\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"38\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:650px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Social Security Number of Card Holder:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:300px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_38_element7\" name=\"wdform_38_element7\" value=\"(Insured--if different from above)\" title=\"(Insured--if different from above)\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"35\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:650px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Primary Card Holder's Name: <\/span><\/div><div class=\"wdform-element-section\" style=\"; width:300px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_35_element7\" name=\"wdform_35_element7\" value=\"(Insured--if different from above)\" title=\"(Insured--if different from above)\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"39\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:650px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">Member ID# of Card Holder:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:300px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_39_element7\" name=\"wdform_39_element7\" value=\"(If different from SSN#)\" title=\"(If different from SSN#)\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"40\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:650px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">DOB of Card Holder:<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:300px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_40_element7\" name=\"wdform_40_element7\" value=\"(Insured--if different from above)\" title=\"(Insured--if different from above)\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"41\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_editor\" class=\"wdform-field\"><h3 style=\"color: #f2773e;\">Student Information (if applicable)<\/h3><div style=\"min-width: 300px; border-top:1px solid\"><\/div><\/div><\/div><div wdid=\"42\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"display:none;; width: 100px;\"><span class=\"wdform-label\"> <\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: inline-block; vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_42_element70\" name=\"wdform_42_element7\" value=\"Elementary\" onclick=\"set_default(&quot;wdform_42&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_42_element70\"><span><\/span>Elementary<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_42_element71\" name=\"wdform_42_element7\" value=\"Middle School\" onclick=\"set_default(&quot;wdform_42&quot;,&quot;1&quot;,&quot;7&quot;); \"  ><label for=\"wdform_42_element71\"><span><\/span>Middle School<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_42_element72\" name=\"wdform_42_element7\" value=\"High School\" onclick=\"set_default(&quot;wdform_42&quot;,&quot;2&quot;,&quot;7&quot;); \"  ><label for=\"wdform_42_element72\"><span><\/span>High School<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_42_element73\" name=\"wdform_42_element7\" value=\"University\" onclick=\"set_default(&quot;wdform_42&quot;,&quot;3&quot;,&quot;7&quot;); \"  ><label for=\"wdform_42_element73\"><span><\/span>University<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"43\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"; width: 125px;\"><span class=\"wdform-label\">Classification:<\/span><\/div><div class=\"wdform-element-section \" style=\"display:block;;\"><div style=\"display: inline-block; vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_43_element70\" name=\"wdform_43_element7\" value=\"Freshman\" onclick=\"set_default(&quot;wdform_43&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_43_element70\"><span><\/span>Freshman<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_43_element71\" name=\"wdform_43_element7\" value=\"Sophomore\" onclick=\"set_default(&quot;wdform_43&quot;,&quot;1&quot;,&quot;7&quot;); \"  ><label for=\"wdform_43_element71\"><span><\/span>Sophomore<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_43_element72\" name=\"wdform_43_element7\" value=\"Junior\" onclick=\"set_default(&quot;wdform_43&quot;,&quot;2&quot;,&quot;7&quot;); \"  ><label for=\"wdform_43_element72\"><span><\/span>Junior<\/label><\/div><\/div><\/div><div style=\"display: inline-block;  vertical-align:top\"><div style=\"display: table-row;\"><div class=\"radio-div forlabs fm-right\" ><input type=\"radio\"  id=\"wdform_43_element73\" name=\"wdform_43_element7\" value=\"Senior\" onclick=\"set_default(&quot;wdform_43&quot;,&quot;3&quot;,&quot;7&quot;); \"  ><label for=\"wdform_43_element73\"><span><\/span>Senior<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"44\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_editor\" class=\"wdform-field\"><h3 style=\"color: #f2773e;\">Referral Information<\/h3><div style=\"min-width: 300px; border-top:1px solid\"><\/div><\/div><\/div><div wdid=\"45\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_text\" class=\"wdform-field\" style=\"width:550px\"><div class=\"wdform-label-section\" style=\"float: left; width: 300px;\"><span class=\"wdform-label\">How were you referred to us?<\/span><\/div><div class=\"wdform-element-section\" style=\"; width:200px;\">              <div style=\"display:table; width: 100%;\">              <div style=\"display:table-row;\">                <div style=\"display:none;;\"><span style=\"vertical-align:middle;\"><\/span><\/div>                 <div style=\"display:table-cell;\">              <input type=\"text\" class=\"input_deactive\" id=\"wdform_45_element7\" name=\"wdform_45_element7\" value=\"\" title=\"\"     style=\"width:100%\"><\/div><div style=\"display:table-cell;\"><span style=\"vertical-align:middle;\"><\/span><\/div>              <\/div>\t\t\t                <\/div>\t              <\/div><\/div><\/div><div wdid=\"47\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_editor\" class=\"wdform-field\">Include a brief description of your problem and why you are seeking an assessment.<\/div><\/div><div wdid=\"46\" class=\"wdform_row ui-sortable-handle\" style=\"\"><div type=\"type_textarea\" class=\"wdform-field\"  style=\"width:1010px\"><div class=\"wdform-label-section\" style=\"display:none;; width: 600px;\"><span class=\"wdform-label\">Include a brief description of your problem and why you are seeking an assessment.<\/span><\/div><div class=\"wdform-element-section \" style=\" width: 400px\"><textarea class=\"input_deactive\" id=\"wdform_46_element7\" name=\"wdform_46_element7\" title=\"\"  style=\"width: 100%; height: 100px;\" ><\/textarea><\/div><\/div><\/div><div wdid=\"48\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_editor\" class=\"wdform-field\"><h3 style=\"color: #f2773e;\">Saturday Appointment Agreement<\/h3><div style=\"min-width: 300px; border-top:1px solid\"><\/div><\/div><\/div><div wdid=\"49\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"display:none;; width: 100px;\"><span class=\"wdform-label\">acknowledge<\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: table-row; vertical-align:top\"><div style=\"display: table-cell;\"><div class=\"radio-div forlabs \" style='float: left !important; margin:3px 8px 0 0 !important; display: inline-block !important;'><input type=\"radio\"  id=\"wdform_49_element70\" name=\"wdform_49_element7\" value=\"I, knowing that my account information is private, hereby agree to provide the Clinic for Adult Attention Problems, P.A., with my credit\/debit card information if my initial appointment occurs on a Saturday.\" onclick=\"set_default(&quot;wdform_49&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_49_element70\"><span><\/span>I, knowing that my account information is private, hereby agree to provide the Clinic for Adult Attention Problems, P.A., with my credit\/debit card information if my initial appointment occurs on a Saturday.<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"50\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_radio\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"display:none;; width: 100px;\"><span class=\"wdform-label\">Acknowledge2<\/span><\/div><div class=\"wdform-element-section \" style=\";\"><div style=\"display: table-row; vertical-align:top\"><div style=\"display: table-cell;\"><div class=\"radio-div forlabs \" style='float: left !important; margin:3px 8px 0 0 !important; display: inline-block !important;'><input type=\"radio\"  id=\"wdform_50_element70\" name=\"wdform_50_element7\" value=\" I hereby decline to provide the Clinic for Adult Attention Problems, P.A., with my credit\/debit card information and acknowledge that my initial appointment cannot occur on a Saturday without a method of payment on file.\" onclick=\"set_default(&quot;wdform_50&quot;,&quot;0&quot;,&quot;7&quot;); \"  ><label for=\"wdform_50_element70\"><span><\/span> I hereby decline to provide the Clinic for Adult Attention Problems, P.A., with my credit\/debit card information and acknowledge that my initial appointment cannot occur on a Saturday without a method of payment on file.<\/label><\/div><\/div><\/div><\/div><\/div><\/div><div wdid=\"53\" class=\"wdform_row ui-sortable-handle\" style=\"\"> <script src=\"https:\/\/www.google.com\/recaptcha\/api.js\"><\/script><div type=\"type_recaptcha\" class=\"wdform-field\"><div class=\"wdform-label-section\" style=\"float: left;; width: 200px;\"><span class=\"wdform-label\">Recaptcha Word Verification:<\/span><\/div><div class=\"wdform-element-section *:*w_theme*:*\" style=\";\"><div class=\"g-recaptcha\" data-sitekey=\"6LdmwZ0UAAAAAPT2A1qCOlDLex5H0uTHKqwkFOSY\"><\/div><\/div><\/div><\/div><div wdid=\"52\" class=\"wdform_row ui-sortable-handle\"><div type=\"type_submit_reset\" class=\"wdform-field fm-subscribe-reset\"><div class=\"wdform-label-section\" style=\"display: table-cell;\"><\/div><div class=\"wdform-element-section \" style=\"display: table-cell;\"><button type=\"button\" class=\"button-submit\" onclick=\"check_required7('submit', '7');\" >Submit<\/button><button type=\"button\" class=\"button-reset\" onclick=\"check_required7('reset', 7);\"  >Reset<\/button><\/div><\/div><\/div><\/div><\/div><div valign=\"top\" class=\"wdform_footer\" style=\"width: 100%;\"><div style=\"width: 100%;\"><div style=\"width: 100%; display: table; padding-top:10px;\"><div style=\"display: table-row-group;\"><div id=\"7page_nav1\" style=\"display: table-row;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_preload\"><\/div><\/form><\/div>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>For an Evaluation or For Behavioral Therapy Note:\u00a0All information received from this site is held in a secure server and kept confidential. Only authorized personnel will view this information. &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/pages\/2"}],"collection":[{"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/comments?post=2"}],"version-history":[{"count":6,"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/pages\/2\/revisions"}],"predecessor-version":[{"id":95,"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/pages\/2\/revisions\/95"}],"wp:attachment":[{"href":"https:\/\/pcasecure.com\/adultatt\/wp-json\/wp\/v2\/media?parent=2"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}