{"id":1140,"date":"2023-09-06T20:50:40","date_gmt":"2023-09-06T10:50:40","guid":{"rendered":"https:\/\/beachesbrainclinic.com.au\/?page_id=1140"},"modified":"2023-09-06T23:48:21","modified_gmt":"2023-09-06T13:48:21","slug":"referral-contact","status":"publish","type":"page","link":"https:\/\/beachesbrainclinic.com.au\/index.php\/referral-contact\/","title":{"rendered":"Referral contact"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1140\" class=\"elementor elementor-1140\">\n\t\t\t\t\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-2cdd7a3 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2cdd7a3\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-bd2bfa8\" data-id=\"bd2bfa8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-b7e4124 elementor-widget elementor-widget-heading\" data-id=\"b7e4124\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 02-08-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Refer to Us<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-68cad68 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"68cad68\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-e3c50bc\" data-id=\"e3c50bc\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-558a31b elementor-widget elementor-widget-heading\" data-id=\"558a31b\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Please complete our referral form and we will get back to you as soon as possible.<\/h5>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-4f7727f\" data-id=\"4f7727f\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4c5198a elementor-widget elementor-widget-text-editor\" data-id=\"4c5198a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 02-08-2023 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>If you think your client or patient would benefit from a cognitive assessment, please get in touch with us by submitting this form and we will contact you to discuss your client&#8217;s needs further.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-e86b8c3 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e86b8c3\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-4d3e996\" data-id=\"4d3e996\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-64f1cf3 elementor-widget elementor-widget-wpforms\" data-id=\"64f1cf3\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"wpforms-container \" id=\"wpforms-1134\"><form id=\"wpforms-form-1134\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1134\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/1140\" data-token=\"e1912f778be10925fdb14d9a445a3dc7\" data-token-time=\"1775771963\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1134-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-1134-field_0\">Referring Practitioner Details <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1134-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" placeholder=\"First name\" required><label for=\"wpforms-1134-field_0\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1134-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" placeholder=\"Last name\" required><label for=\"wpforms-1134-field_0-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1134-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_5\">Referrer organisation <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1134-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" placeholder=\"Organisation\" required><\/div><div id=\"wpforms-1134-field_6-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"6\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_6\">Referrer Profession <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-1134-field_6\" class=\"wpforms-field-large wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-large\" data-search-enabled=\"1\" name=\"wpforms[fields][6]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Profession<\/option><option value=\"Neurologist\" >Neurologist<\/option><option value=\"Psychiatrist\" >Psychiatrist<\/option><option value=\"Paediatrician\" >Paediatrician<\/option><option value=\"General Practitioner\" >General Practitioner<\/option><option value=\"Psychologist\" >Psychologist<\/option><option value=\"Physiotherapist\" >Physiotherapist<\/option><option value=\"Occupational Therapist\" >Occupational Therapist<\/option><option value=\"Speech Pathologist\" >Speech Pathologist<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1134-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_1\">Referrer Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1134-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"Email address\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1134-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_18\">Referrer contact number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1134-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" placeholder=\"Best Contact Number\" required><\/div><div id=\"wpforms-1134-field_7-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1134-field_7\">Client\/Patient details <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1134-field_7\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][7][first]\" placeholder=\"First name\" required><label for=\"wpforms-1134-field_7\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1134-field_7-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][7][last]\" placeholder=\"Last name\" required><label for=\"wpforms-1134-field_7-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1134-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_8\">DOB <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1134-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" placeholder=\"Date of Birth\" required><\/div><div id=\"wpforms-1134-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"11\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_11\">Sex <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-1134-field_11\" class=\"wpforms-field-medium wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Sex<\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><\/select><\/div><div id=\"wpforms-1134-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_19\">Client contact number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1134-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" placeholder=\"Phone number\" required><\/div><div id=\"wpforms-1134-field_13-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"13\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_13\">Client Email<\/label><input type=\"email\" id=\"wpforms-1134-field_13\" class=\"wpforms-field-large\" name=\"wpforms[fields][13]\" placeholder=\"Email address\" spellcheck=\"false\" ><\/div><div id=\"wpforms-1134-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_2\">Reason for Referral <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1134-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" placeholder=\"Reason for Referral e.g. purpose of assessment and\/or specific referral question to be answered\" required><\/textarea><\/div><div id=\"wpforms-1134-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_14\">Presenting issues <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1134-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" placeholder=\"Presenting cognitive and\/or psychological difficulties, or symtoms of concern\" required><\/textarea><\/div><div id=\"wpforms-1134-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_15\">Diagnoses<\/label><textarea id=\"wpforms-1134-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" placeholder=\"Any current diagnoses (if known, please specify)\" ><\/textarea><\/div><div id=\"wpforms-1134-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_16\">Current medications<\/label><textarea id=\"wpforms-1134-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" placeholder=\"Any current medications (if known, please specify)\" ><\/textarea><\/div><div id=\"wpforms-1134-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1134-field_17\">Medical history<\/label><textarea id=\"wpforms-1134-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" placeholder=\"Any known medical history and\/or hearing, vision or mobility difficulties\" ><\/textarea><\/div><div id=\"wpforms-1134-field_20-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"20\"><input type=\"hidden\" id=\"wpforms-1134-field_20\" name=\"wpforms[fields][20]\" value=\"__user_city__\"><\/div><div id=\"wpforms-1134-field_21-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"21\"><input type=\"hidden\" id=\"wpforms-1134-field_21\" name=\"wpforms[fields][21]\" value=\"__user_country__\"><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6Lf1ZqknAAAAAJ9klrCLApfhvp7mGasSeOq5XO9j\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1134\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1140\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1134\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/beachesbrainclinic.com.au\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-fda3d87\" data-id=\"fda3d87\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Refer to Us Please complete our referral form and we will get back to you as soon as possible. If you think your client or patient would benefit from a cognitive assessment, please get in touch with us by submitting this form and we will contact you to discuss your client&#8217;s needs further.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","footnotes":""},"class_list":["post-1140","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1140","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/comments?post=1140"}],"version-history":[{"count":31,"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1140\/revisions"}],"predecessor-version":[{"id":1189,"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1140\/revisions\/1189"}],"wp:attachment":[{"href":"https:\/\/beachesbrainclinic.com.au\/index.php\/wp-json\/wp\/v2\/media?parent=1140"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}