{"id":3428,"date":"2024-02-29T20:41:38","date_gmt":"2024-02-29T20:41:38","guid":{"rendered":"https:\/\/rhinowebllc.com\/journeyccservices\/?page_id=3428"},"modified":"2024-03-27T21:12:36","modified_gmt":"2024-03-27T21:12:36","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/rhinowebllc.com\/journeyccservices\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"<section data-bb-version=\"4.8.4\" id=\"bt_bb_section6a0b87bf75a78\" class=\"bt_bb_section bt_bb_color_scheme_1 bt_bb_layout_boxed_1400 bt_bb_vertical_align_top bt_bb_background_overlay_dark_solid bt_bb_top_spacing_medium bt_bb_bottom_spacing_large bt_bb_negative_margin_none\" style=\"; --section-primary-color:#ffffff; --section-secondary-color:#181818;\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_medium&quot;,&quot;xxl&quot;:&quot;medium&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;xxl&quot;:&quot;large&quot;},&quot;bt_bb_negative_margin_&quot;:{&quot;current_class&quot;:&quot;bt_bb_negative_margin_none&quot;,&quot;xxl&quot;:&quot;none&quot;}}\"><div class=\"bt_bb_background_image_holder_wrapper\"><div class=\"bt_bb_background_image_holder btLazyLoadBackground bt_bb_parallax\"  data-background_image_src=\"https:\/\/rhinowebllc.com\/journeyccservices\/wp-content\/uploads\/2024\/02\/header.jpg\" data-parallax=\"0.7\" data-parallax-offset=\"0\" data-parallax-zoom-start=\"1\" data-parallax-zoom-end=\"1\" data-parallax-blur-start=\"0\" data-parallax-blur-end=\"0\" data-parallax-opacity-start=\"1\" data-parallax-opacity-end=\"1\" style=\" background-image: url(&#039;https:\/\/rhinowebllc.com\/journeyccservices\/wp-content\/plugins\/bold-page-builder\/img\/blank.gif&#039;);\"><\/div><\/div><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row_wrapper\"><div  class=\"bt_bb_row\"  data-bt-override-class=\"{}\"><div  class=\"bt_bb_column col-xl-8 col-xs-12 col-sm-12 col-md-12 col-lg-8 bt_bb_align_left bt_bb_vertical_align_top bt_bb_padding_none bt_bb_border_thickness_1 bt_bb_animation_fade_in animate\"  data-width=\"8\" data-bt-override-class=\"{&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_left&quot;,&quot;xxl&quot;:&quot;left&quot;,&quot;xl&quot;:&quot;left&quot;},&quot;bt_bb_padding_&quot;:{&quot;current_class&quot;:&quot;bt_bb_padding_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;,&quot;xl&quot;:&quot;1&quot;}}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><div class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_large bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;xxl&quot;:&quot;large&quot;,&quot;xl&quot;:&quot;large&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;,&quot;xl&quot;:&quot;1&quot;},&quot;bt_bb_icon_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_icon_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;},&quot;bt_bb_text_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_text_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_separator_v2_inner\"><span class=\"bt_bb_separator_v2_inner_before\"><\/span><span class=\"bt_bb_separator_v2_inner_content\"><span  data-ico-=\"\" class=\"bt_bb_icon_holder\"><\/span><\/span><span class=\"bt_bb_separator_v2_inner_after\"><\/span><\/div><\/div><header data-bb-version=\"4.8.4\" class=\"bt_bb_headline bt_bb_subheadline_text_transform_default bt_bb_dash_top bt_bb_superheadline bt_bb_size_huge bt_bb_align_inherit\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_huge&quot;,&quot;xxl&quot;:&quot;huge&quot;,&quot;md&quot;:&quot;large&quot;,&quot;sm&quot;:&quot;large&quot;,&quot;xs&quot;:&quot;large&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;xxl&quot;:&quot;inherit&quot;}}\"><h1 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_superheadline\">FORMS<\/span><span class=\"bt_bb_headline_content\"><span>Referral Form<\/span><\/span><\/h1><\/header><div class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_normal bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;,&quot;xl&quot;:&quot;1&quot;},&quot;bt_bb_icon_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_icon_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;},&quot;bt_bb_text_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_text_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_separator_v2_inner\"><span class=\"bt_bb_separator_v2_inner_before\"><\/span><span class=\"bt_bb_separator_v2_inner_content\"><span  data-ico-=\"\" class=\"bt_bb_icon_holder\"><\/span><\/span><span class=\"bt_bb_separator_v2_inner_after\"><\/span><\/div><\/div><div data-bb-version=\"4.8.4\" class=\"bt_bb_button bt_bb_color_scheme_6 bt_bb_icon_position_left bt_bb_style_filled bt_bb_size_medium bt_bb_width_inline bt_bb_shape_inherit bt_bb_target_self bt_bb_text_transform_inherit bt_bb_align_inherit\" style=\"; --primary-color:#ffffff; --secondary-color:var(--accent-color);\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_medium&quot;,&quot;xxl&quot;:&quot;medium&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;xxl&quot;:&quot;inherit&quot;}}\"><a href=\"https:\/\/rhinowebllc.com\/journeyccservices\/contact\/\" target=\"_self\" class=\"bt_bb_link\" title=\"GET YOUR FREE CONSULTATION\"><span class=\"bt_bb_button_text\" >GET YOUR FREE CONSULTATION<\/span><\/a><\/div><\/div><\/div><\/div><div  class=\"bt_bb_column col-xl-4 col-xs-12 col-sm-12 col-md-12 col-lg-4 bt_bb_align_left bt_bb_vertical_align_top bt_bb_padding_normal bt_bb_shape_no bt_bb_shape_position_no bt_bb_shadow_position_no bt_bb_overlay_no\"  data-width=\"4\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><\/div><\/div><\/div><\/div><\/div><\/div><!-- cell_inner --><\/div><!-- cell --><\/div><!-- port --><\/section><section data-bb-version=\"4.8.4\" id=\"bt_bb_section6a0b87bf75fd6\" class=\"bt_bb_section bt_bb_layout_boxed_1400 bt_bb_vertical_align_top bt_bb_top_spacing_large bt_bb_bottom_spacing_large bt_bb_negative_margin_none bt_bb_negative_margin_none\"  data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_large&quot;,&quot;xxl&quot;:&quot;large&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;xxl&quot;:&quot;large&quot;},&quot;bt_bb_negative_margin_&quot;:{&quot;current_class&quot;:&quot;bt_bb_negative_margin_none&quot;,&quot;xxl&quot;:&quot;none&quot;}}\"><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row_wrapper\"><div  class=\"bt_bb_row bt_bb_column_gap_0 bt_bb_negative_margin_ bt_bb_negative_margin_\"  data-bt-override-class=\"{&quot;bt_bb_negative_margin_&quot;:{&quot;current_class&quot;:&quot;bt_bb_negative_margin_&quot;,&quot;xxl&quot;:&quot;&quot;,&quot;xl&quot;:&quot;&quot;}}\"><div data-bb-version=\"4.8.4\"  class=\"bt_bb_column col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_align_left bt_bb_vertical_align_middle bt_bb_padding_50 bt_bb_border_thickness_1 bt_bb_color_scheme_11 bt_bb_highlight bt_bb_shape_rounded bt_bb_shape_position_inner bt_bb_shadow_position_regular bt_bb_animation_fade_in animate\" style=\"; --column-primary-color:#181818; --column-secondary-color:#f1f1f1;\" data-width=\"12\" data-bt-override-class=\"{&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_left&quot;,&quot;xxl&quot;:&quot;left&quot;},&quot;bt_bb_padding_&quot;:{&quot;current_class&quot;:&quot;bt_bb_padding_50&quot;,&quot;xxl&quot;:&quot;50&quot;,&quot;md&quot;:&quot;10&quot;,&quot;sm&quot;:&quot;20&quot;,&quot;xs&quot;:&quot;20&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;}}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><div class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_large bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;xxl&quot;:&quot;large&quot;,&quot;xl&quot;:&quot;large&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;,&quot;xl&quot;:&quot;1&quot;},&quot;bt_bb_icon_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_icon_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;},&quot;bt_bb_text_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_text_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_separator_v2_inner\"><span class=\"bt_bb_separator_v2_inner_before\"><\/span><span class=\"bt_bb_separator_v2_inner_content\"><span  data-ico-=\"\" class=\"bt_bb_icon_holder\"><\/span><\/span><span class=\"bt_bb_separator_v2_inner_after\"><\/span><\/div><\/div><header data-bb-version=\"4.8.4\" class=\"bt_bb_headline bt_bb_subheadline_text_transform_default bt_bb_dash_top bt_bb_superheadline bt_bb_superheadline_outside bt_bb_subheadline bt_bb_size_large bt_bb_align_inherit\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_large&quot;,&quot;xxl&quot;:&quot;large&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;xxl&quot;:&quot;inherit&quot;}}\"><div class=\"bt_bb_headline_superheadline_outside\"><span class=\"bt_bb_headline_superheadline\">REFERRAL FORM<\/span><\/div><h2 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_content\"><span>Submit your <b>Referral Form<\/b><\/span><\/span><\/h2><div class=\"bt_bb_headline_subheadline\">Functional Family Therapy (FFT) is an intensive, evidence-based program to address complex issues for children and adolescents, aged 10-18 years, who have been referred for emotional and behavioral problems. FFT is home community-based and uses a systematic approach to assist the family with changing maladaptive behaviors.<\/div><\/header><div class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_normal bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;,&quot;xl&quot;:&quot;1&quot;},&quot;bt_bb_icon_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_icon_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;},&quot;bt_bb_text_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_text_size_normal&quot;,&quot;xxl&quot;:&quot;normal&quot;,&quot;xl&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_separator_v2_inner\"><span class=\"bt_bb_separator_v2_inner_before\"><\/span><span class=\"bt_bb_separator_v2_inner_content\"><span  data-ico-=\"\" class=\"bt_bb_icon_holder\"><\/span><\/span><span class=\"bt_bb_separator_v2_inner_after\"><\/span><\/div><\/div><div data-bb-version=\"4.8.4\" class=\"bt_bb_contact_form_7 bt_bb_color_scheme_6\" style=\"; --primary-color:#ffffff; --secondary-color:var(--accent-color);\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3455-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=\"\/journeyccservices\/wp-json\/wp\/v2\/pages\/3428#wpcf7-f3455-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"3455\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3455-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:3455,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-167&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;chkproblems&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;group-937&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;agency&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"bt_bb_cf7_form bt_bb_cf7_twocol_form\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Youth's Name*<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"youth-fullname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Input Fullname(First Middle Last)\" value=\"\" type=\"text\" name=\"youth-fullname\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Birthdate*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"bdate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"bdate\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Age (must be between 10-18)*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"10\" max=\"18\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your age\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Gender*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"rad-gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rad-gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rad-gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rad-gender\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Current Address\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"txt-csz\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City, State, Zip\" value=\"\" type=\"text\" name=\"txt-csz\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parent-guardian1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Parent\/Guardian 1\" value=\"\" type=\"text\" name=\"parent-guardian1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parent-guardian2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Parent\/Guardian 2\" value=\"\" type=\"text\" name=\"parent-guardian2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"home-no\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home\/Cell Phone\" value=\"\" type=\"tel\" name=\"home-no\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Permission to Leave a Message (Home\/Cell)*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rad-permi1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rad-permi1\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rad-permi1\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"work-no\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Work Phone\" value=\"\" type=\"tel\" name=\"work-no\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Permission to Leave a Message (Work)*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rad-permi2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rad-permi2\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rad-permi2\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"alternate-no\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Alternate Phone\" value=\"\" type=\"tel\" name=\"alternate-no\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Permission to Leave a Message (Alternate)*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rad-permi3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rad-permi3\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rad-permi3\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Best contact time*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rad-best\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rad-best\" value=\"Morning(8AM-11AM)\" \/><span class=\"wpcf7-list-item-label\">Morning(8AM-11AM)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rad-best\" value=\"Afternoon(noon-3PM)\" \/><span class=\"wpcf7-list-item-label\">Afternoon(noon-3PM)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rad-best\" value=\"Evening(4PM-7PM)\" \/><span class=\"wpcf7-list-item-label\">Evening(4PM-7PM)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rad-best\" value=\"Anytime\" \/><span class=\"wpcf7-list-item-label\">Anytime<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Presenting Problems*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"chkproblems\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Behavioral Concerns at Home\/School\" \/><span class=\"wpcf7-list-item-label\">Behavioral Concerns at Home\/School<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Depression\/Self-Esteem\/Cutting\" \/><span class=\"wpcf7-list-item-label\">Depression\/Self-Esteem\/Cutting<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Life Issues\/Problems\" \/><span class=\"wpcf7-list-item-label\">Life Issues\/Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Family Conflict\/Relationship Problems\" \/><span class=\"wpcf7-list-item-label\">Family Conflict\/Relationship Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Physical Aggression\" \/><span class=\"wpcf7-list-item-label\">Physical Aggression<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Trauma\" \/><span class=\"wpcf7-list-item-label\">Trauma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Anxiety\" \/><span class=\"wpcf7-list-item-label\">Anxiety<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Parenting\" \/><span class=\"wpcf7-list-item-label\">Parenting<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Substance Abuse\" \/><span class=\"wpcf7-list-item-label\">Substance Abuse<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"chkproblems[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"group-167\" data-orig_data_id=\"group-167\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"otherproblem\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Input here if not listed above\" value=\"\" type=\"text\" name=\"otherproblem\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<p><label class=\"x_label\">Has the client been diagnosed with a behavioral or mental health disorder in the past? If yes, previous diagnosis?<\/label>\n\t\t<\/p>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"past-treat\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Past Treatment\" name=\"past-treat\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><label class=\"x_label\">Referral Source Name*<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"agency\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"agency\"><option value=\"\">Referral Agency<\/option><option value=\"DCFS\">DCFS<\/option><option value=\"OJJ\">OJJ<\/option><option value=\"Choices CoSC\">Choices CoSC<\/option><option value=\"FINS\">FINS<\/option><option value=\"School\">School<\/option><option value=\"Self-referred\">Self-referred<\/option><option value=\"CAS\">CAS<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"group-937\" data-orig_data_id=\"group-937\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"otheragency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Input Referral Agency not listed above\" value=\"\" type=\"text\" name=\"otheragency\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referral-fullname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referral Full Name\" value=\"\" type=\"text\" name=\"referral-fullname\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referral-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone Number\" value=\"\" type=\"tel\" name=\"referral-phone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referral-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"referral-email\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"bt_bb_cf7_button bt_bb_width_full\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"SUBMIT FORM\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div><div class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_large bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" 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class=\"bt_bb_background_image_holder_wrapper\"><div class=\"bt_bb_background_image_holder btLazyLoadBackground\"  data-background_image_src=\"https:\/\/rhinowebllc.com\/journeyccservices\/wp-content\/uploads\/2024\/02\/Depositphotos_289467186_L.jpg\" data-parallax-zoom-start=\"1\" data-parallax-zoom-end=\"1\" data-parallax-blur-start=\"0\" data-parallax-blur-end=\"0\" data-parallax-opacity-start=\"1\" data-parallax-opacity-end=\"1\" style=\" background-image: url(&#039;https:\/\/rhinowebllc.com\/journeyccservices\/wp-content\/plugins\/bold-page-builder\/img\/blank.gif&#039;);\"><\/div><\/div><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row_wrapper\"><div  class=\"bt_bb_row\"  data-bt-override-class=\"{}\"><div data-bb-version=\"4.8.4\"  class=\"bt_bb_column col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_align_center bt_bb_vertical_align_top bt_bb_padding_none bt_bb_border_thickness_1 bt_bb_shadow_position_regular\"  data-width=\"12\" data-bt-override-class=\"{&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_center&quot;,&quot;xxl&quot;:&quot;center&quot;},&quot;bt_bb_padding_&quot;:{&quot;current_class&quot;:&quot;bt_bb_padding_none&quot;,&quot;xxl&quot;:&quot;none&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;xxl&quot;:&quot;1&quot;}}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><header data-bb-version=\"4.8.4\" class=\"bt_bb_headline bt_bb_subheadline_text_transform_default bt_bb_color_scheme_1 bt_bb_dash_none bt_bb_size_large bt_bb_align_inherit\" style=\"; --primary-color:#ffffff; --secondary-color:#181818;\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_large&quot;,&quot;xxl&quot;:&quot;large&quot;,&quot;md&quot;:&quot;normal&quot;,&quot;sm&quot;:&quot;normal&quot;,&quot;xs&quot;:&quot;normal&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;xxl&quot;:&quot;inherit&quot;}}\"><h4 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_content\"><span>The journey to better mental and emotional health is not always easy but it is well worth it in living your best life.<\/span><\/span><\/h4><\/header><div data-bb-version=\"4.8.4\" class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_normal bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" 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--><\/section>","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":""},"class_list":["post-3428","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/pages\/3428","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/comments?post=3428"}],"version-history":[{"count":32,"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/pages\/3428\/revisions"}],"predecessor-version":[{"id":3811,"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/pages\/3428\/revisions\/3811"}],"wp:attachment":[{"href":"https:\/\/rhinowebllc.com\/journeyccservices\/wp-json\/wp\/v2\/media?parent=3428"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}