{"id":366,"date":"2020-11-05T15:54:16","date_gmt":"2020-11-05T15:54:16","guid":{"rendered":"http:\/\/luciaconte.com\/?page_id=366"},"modified":"2020-11-05T15:56:34","modified_gmt":"2020-11-05T15:56:34","slug":"screening_3","status":"publish","type":"page","link":"http:\/\/luciaconte.com\/index.php\/screening_3\/","title":{"rendered":"Screening With References"},"content":{"rendered":"\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f369-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/366#wpcf7-f369-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"369\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f369-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p><label> Provider 1 Name<br \/>\n  <span class=\"wpcf7-form-control-wrap pname1\"><input type=\"text\" name=\"pname1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n<\/label><\/p>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Phone<br \/>\n    <span class=\"wpcf7-form-control-wrap phone1\"><input type=\"text\" name=\"phone1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Email<br \/>\n  <span class=\"wpcf7-form-control-wrap email1\"><input type=\"email\" name=\"email1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Website<br \/>\n    <span class=\"wpcf7-form-control-wrap web1\"><input type=\"text\" name=\"web1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Remembers you as<br \/>\n  <span class=\"wpcf7-form-control-wrap r1\"><input type=\"text\" name=\"r1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<p><label> Provider 2 Name<br \/>\n  <span class=\"wpcf7-form-control-wrap pname2\"><input type=\"text\" name=\"pname2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n<\/label><\/p>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Phone<br \/>\n    <span class=\"wpcf7-form-control-wrap phone2\"><input type=\"text\" name=\"phone2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Email<br \/>\n  <span class=\"wpcf7-form-control-wrap email2\"><input type=\"email\" name=\"email2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Website<br \/>\n    <span class=\"wpcf7-form-control-wrap web2\"><input type=\"text\" name=\"web2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Remembers you as<br \/>\n  <span class=\"wpcf7-form-control-wrap r2\"><input type=\"text\" name=\"r2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<p><label> Provider 3 Name<br \/>\n  <span class=\"wpcf7-form-control-wrap pname3\"><input type=\"text\" name=\"pname3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n<\/label><\/p>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Phone<br \/>\n    <span class=\"wpcf7-form-control-wrap phone3\"><input type=\"text\" name=\"phone3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Email<br \/>\n  <span class=\"wpcf7-form-control-wrap email3\"><input type=\"email\" name=\"email3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Website<br \/>\n    <span class=\"wpcf7-form-control-wrap web3\"><input type=\"text\" name=\"web3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Remembers you as<br \/>\n  <span class=\"wpcf7-form-control-wrap r3\"><input type=\"text\" name=\"r3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<p><label> Provider 4 Name<br \/>\n  <span class=\"wpcf7-form-control-wrap pname4\"><input type=\"text\" name=\"pname4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n<\/label><\/p>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Phone<br \/>\n    <span class=\"wpcf7-form-control-wrap phone4\"><input type=\"text\" name=\"phone4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Email<br \/>\n  <span class=\"wpcf7-form-control-wrap email4\"><input type=\"email\" name=\"email4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Website<br \/>\n    <span class=\"wpcf7-form-control-wrap web4\"><input type=\"text\" name=\"web4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Remembers you as<br \/>\n  <span class=\"wpcf7-form-control-wrap r4\"><input type=\"text\" name=\"r4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<h4>Contact Information<\/h4>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> How do you wish to be contacted?<br \/>\n    <span class=\"wpcf7-form-control-wrap wish\"><input type=\"text\" name=\"wish\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Phone\/text\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Email<br \/>\n  <span class=\"wpcf7-form-control-wrap email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Email\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<h4>Appointment Details<\/h4>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Preferred Dates\/Times*<br \/>\n    <span class=\"wpcf7-form-control-wrap app\"><input type=\"text\" name=\"app\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"please note I am not available weekdays before 5pm.\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Preferred Location (my place is near Northpark Mall. If I\u2019m visiting you, please provide general area.)<br \/>\n   <span class=\"wpcf7-form-control-wrap place\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">My Place<\/span><input type=\"radio\" name=\"place\" value=\"My Place\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Your Place<\/span><input type=\"radio\" name=\"place\" value=\"Your Place\" \/><\/label><\/span><\/span><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Preferred visit Length<br \/>\n    <span class=\"wpcf7-form-control-wrap visit-len\"><input type=\"text\" name=\"visit-len\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<div class=\"content-column one_half\">\n<div style=\"padding:\"0;\">\n<label> Traveler to this Area?<br \/>\n   <span class=\"wpcf7-form-control-wrap visit-area\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"radio\" name=\"visit-area\" value=\"Yes\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"visit-area\" value=\"No\" \/><\/label><\/span><\/span><\/span><br \/>\n <\/label><\/div>\n<\/div>\n<p><label> Social Media\/Board Usernames<br \/>\n  <span class=\"wpcf7-form-control-wrap social\"><input type=\"text\" name=\"social\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap intro\"><textarea name=\"intro\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea tx\" aria-invalid=\"false\" placeholder=\"Brief intro\"><\/textarea><\/span><\/p>\n<p><input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/pages\/366"}],"collection":[{"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/comments?post=366"}],"version-history":[{"count":4,"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/pages\/366\/revisions"}],"predecessor-version":[{"id":371,"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/pages\/366\/revisions\/371"}],"wp:attachment":[{"href":"http:\/\/luciaconte.com\/index.php\/wp-json\/wp\/v2\/media?parent=366"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}