{"id":558,"date":"2022-08-08T02:10:05","date_gmt":"2022-08-08T02:10:05","guid":{"rendered":"https:\/\/hopeinhealingfamilyservices.com\/?page_id=558"},"modified":"2022-08-08T02:10:26","modified_gmt":"2022-08-08T02:10:26","slug":"new-client-information","status":"publish","type":"page","link":"https:\/\/hopeinhealingfamilyservices.com\/?page_id=558","title":{"rendered":"New Client Information"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-557 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-557\" data-uid=\"69e7564cc4ab0\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-557\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-557 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"557\"\n\t\t\t\t\n\t\t\t\tdata-design=\"default\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e7564cc4ab0\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e7564cc4ab0\" id=\"forminator-field-name-1_69e7564cc4ab0-label\" class=\"forminator-label\">Client First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John\" id=\"forminator-field-name-1_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e7564cc4ab0\" id=\"forminator-field-name-2_69e7564cc4ab0-label\" class=\"forminator-label\">Client Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. Doe\" id=\"forminator-field-name-2_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e7564cc4ab0\" id=\"forminator-field-address-1-street_address_69e7564cc4ab0-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 123 Sesame St\" id=\"forminator-field-address-1-street_address_69e7564cc4ab0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e7564cc4ab0\" id=\"forminator-field-address-1-city_69e7564cc4ab0-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"E.g. Greenville\" id=\"forminator-field-address-1-city_69e7564cc4ab0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_69e7564cc4ab0\" id=\"forminator-field-address-1-state_69e7564cc4ab0-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"E.g. NC\" id=\"forminator-field-address-1-state_69e7564cc4ab0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e7564cc4ab0\" id=\"forminator-field-address-1-zip_69e7564cc4ab0-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"E.g. 27858\" id=\"forminator-field-address-1-zip_69e7564cc4ab0\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e7564cc4ab0\" id=\"forminator-field-phone-1_69e7564cc4ab0-label\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-1_69e7564cc4ab0\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69e7564cc4ab0\" id=\"forminator-field-email-2_69e7564cc4ab0-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-2_69e7564cc4ab0\" class=\"forminator-input forminator-email--field\" data-required=\"true\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69e7564cc4ab0\" id=\"forminator-field-text-1_69e7564cc4ab0-label\" class=\"forminator-label\">Emergency Contact <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"E.g. Jane Doe\" id=\"forminator-field-text-1_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e7564cc4ab0\" id=\"forminator-field-phone-2_69e7564cc4ab0-label\" class=\"forminator-label\">Emergency Contact Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-2_69e7564cc4ab0\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69e7564cc4ab0-label\"><span id=\"forminator-checkbox-group-69e7564cc4ab0-label\" class=\"forminator-label\">Responsible Party:<\/span><label id=\"forminator-field-checkbox-1-1-69e7564cc4ab0-label\" for=\"forminator-field-checkbox-1-1-69e7564cc4ab0\" class=\"forminator-checkbox\" title=\"Self-Pay\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Self-Pay\" id=\"forminator-field-checkbox-1-1-69e7564cc4ab0\" aria-labelledby=\"forminator-field-checkbox-1-1-69e7564cc4ab0-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69e7564cc4ab0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Self-Pay<\/span><\/label><span id=\"forminator-field-checkbox-1-69e7564cc4ab0-description\" class=\"forminator-description\">Check if Responsible Party and Client are the same.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69e7564cc4ab0\" id=\"forminator-field-name-3_69e7564cc4ab0-label\" class=\"forminator-label\">Responsible Party Name<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-3_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e7564cc4ab0\" id=\"forminator-field-date-1-picker_69e7564cc4ab0-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_69e7564cc4ab0\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69e7564cc4ab0\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69e7564cc4ab0\" id=\"forminator-field-text-2_69e7564cc4ab0-label\" class=\"forminator-label\">Relationship to Client<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"E.g. Mother\" id=\"forminator-field-text-2_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_69e7564cc4ab0\" id=\"forminator-field-phone-3_69e7564cc4ab0-label\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-3_69e7564cc4ab0\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e7564cc4ab0\" id=\"forminator-field-email-1_69e7564cc4ab0-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_69e7564cc4ab0\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_69e7564cc4ab0\" id=\"forminator-field-address-2-street_address_69e7564cc4ab0-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"E.g. 123 Sesame St\" id=\"forminator-field-address-2-street_address_69e7564cc4ab0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_69e7564cc4ab0\" id=\"forminator-field-address-2-city_69e7564cc4ab0-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"E.g. Greenville\" id=\"forminator-field-address-2-city_69e7564cc4ab0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><div id=\"address-2-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-state_69e7564cc4ab0\" id=\"forminator-field-address-2-state_69e7564cc4ab0-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"E.g. NC\" id=\"forminator-field-address-2-state_69e7564cc4ab0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_69e7564cc4ab0\" id=\"forminator-field-address-2-zip_69e7564cc4ab0-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"E.g. 27858\" id=\"forminator-field-address-2-zip_69e7564cc4ab0\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69e7564cc4ab0-label\"><span id=\"forminator-checkbox-group-69e7564cc4ab0-label\" class=\"forminator-label\">Payment Options<\/span><label id=\"forminator-field-checkbox-2-1-69e7564cc4ab0-label\" for=\"forminator-field-checkbox-2-1-69e7564cc4ab0\" class=\"forminator-checkbox\" title=\"Filing Insurance\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Filing-Insurance\" id=\"forminator-field-checkbox-2-1-69e7564cc4ab0\" aria-labelledby=\"forminator-field-checkbox-2-1-69e7564cc4ab0-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-2-69e7564cc4ab0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Filing Insurance<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69e7564cc4ab0-label\" for=\"forminator-field-checkbox-2-2-69e7564cc4ab0\" class=\"forminator-checkbox\" title=\"Out of Pocket\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Out-of-Pocket\" id=\"forminator-field-checkbox-2-2-69e7564cc4ab0\" aria-labelledby=\"forminator-field-checkbox-2-2-69e7564cc4ab0-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-2-69e7564cc4ab0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Out of Pocket<\/span><\/label><span id=\"forminator-field-checkbox-2-69e7564cc4ab0-description\" class=\"forminator-description\">Please check whether you want to file insurance or pay out of pocket.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e7564cc4ab0\" id=\"forminator-field-text-3_69e7564cc4ab0-label\" class=\"forminator-label\">Insurance Company<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"E.g. BCBS\" id=\"forminator-field-text-3_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_69e7564cc4ab0\" id=\"forminator-field-phone-4_69e7564cc4ab0-label\" class=\"forminator-label\">Insurance Phone<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-4_69e7564cc4ab0\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69e7564cc4ab0\" id=\"forminator-field-text-4_69e7564cc4ab0-label\" class=\"forminator-label\">Subscriber Number<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69e7564cc4ab0\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69e7564cc4ab0\" id=\"forminator-field-text-5_69e7564cc4ab0-label\" class=\"forminator-label\">Primary Care Holder<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"E.g. 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