{"id":2131,"date":"2025-04-28T03:15:26","date_gmt":"2025-04-28T03:15:26","guid":{"rendered":"https:\/\/dreamlightaba.com\/?page_id=2131"},"modified":"2025-04-28T03:19:12","modified_gmt":"2025-04-28T03:19:12","slug":"request-services","status":"publish","type":"page","link":"https:\/\/dreamlightaba.com\/index.php\/request-services\/","title":{"rendered":"Request Services"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2131\" class=\"elementor elementor-2131\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d40a010 elementor-section-boxed elementor-section-height-default elementor-section-height-default elementor-invisible\" data-id=\"d40a010\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;fadeInUp&quot;,&quot;shape_divider_bottom&quot;:&quot;clouds&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 283.5 27.8\" preserveAspectRatio=\"xMidYMax slice\">\n  <path class=\"elementor-shape-fill\" d=\"M0 0v6.7c1.9-.8 4.7-1.4 8.5-1 9.5 1.1 11.1 6 11.1 6s2.1-.7 4.3-.2c2.1.5 2.8 2.6 2.8 2.6s.2-.5 1.4-.7c1.2-.2 1.7.2 1.7.2s0-2.1 1.9-2.8c1.9-.7 3.6.7 3.6.7s.7-2.9 3.1-4.1 4.7 0 4.7 0 1.2-.5 2.4 0 1.7 1.4 1.7 1.4h1.4c.7 0 1.2.7 1.2.7s.8-1.8 4-2.2c3.5-.4 5.3 2.4 6.2 4.4.4-.4 1-.7 1.8-.9 2.8-.7 4 .7 4 .7s1.7-5 11.1-6c9.5-1.1 12.3 3.9 12.3 3.9s1.2-4.8 5.7-5.7c4.5-.9 6.8 1.8 6.8 1.8s.6-.6 1.5-.9c.9-.2 1.9-.2 1.9-.2s5.2-6.4 12.6-3.3c7.3 3.1 4.7 9 4.7 9s1.9-.9 4 0 2.8 2.4 2.8 2.4 1.9-1.2 4.5-1.2 4.3 1.2 4.3 1.2.2-1 1.4-1.7 2.1-.7 2.1-.7-.5-3.1 2.1-5.5 5.7-1.4 5.7-1.4 1.5-2.3 4.2-1.1c2.7 1.2 1.7 5.2 1.7 5.2s.3-.1 1.3.5c.5.4.8.8.9 1.1.5-1.4 2.4-5.8 8.4-4 7.1 2.1 3.5 8.9 3.5 8.9s.8-.4 2 0 1.1 1.1 1.1 1.1 1.1-1.1 2.3-1.1 2.1.5 2.1.5 1.9-3.6 6.2-1.2 1.9 6.4 1.9 6.4 2.6-2.4 7.4 0c3.4 1.7 3.9 4.9 3.9 4.9s3.3-6.9 10.4-7.9 11.5 2.6 11.5 2.6.8 0 1.2.2c.4.2.9.9.9.9s4.4-3.1 8.3.2c1.9 1.7 1.5 5 1.5 5s.3-1.1 1.6-1.4c1.3-.3 2.3.2 2.3.2s-.1-1.2.5-1.9 1.9-.9 1.9-.9-4.7-9.3 4.4-13.4c5.6-2.5 9.2.9 9.2.9s5-6.2 15.9-6.2 16.1 8.1 16.1 8.1.7-.2 1.6-.4V0H0z\"\/>\n<\/svg>\n\t\t<\/div>\n\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-25fe1c11\" data-id=\"25fe1c11\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-62c19579 elementor-widget elementor-widget-heading\" data-id=\"62c19579\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Request Services<\/h1>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-54f19f0c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"54f19f0c\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-36c1691f elementor-invisible\" data-id=\"36c1691f\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;fadeInLeft&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-622516b elementor-widget elementor-widget-metform\" data-id=\"622516b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"metform.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div id=\"mf-response-props-id-1152\" data-previous-steps-style=\"\" data-editswitchopen=\"\" data-response_type=\"alert\" data-erroricon=\"fas fa-exclamation-triangle\" data-successicon=\"fas fa-check\" data-messageposition=\"top\" class=\"   mf-scroll-top-no\">\n\t\t<div class=\"formpicker_warper formpicker_warper_editable\" data-metform-formpicker-key=\"1152\" >\n\t\t\t\t\n\t\t\t<div class=\"mf-widget-container\">\n\t\t\t\t\r\n\t\t<div\r\n\t\t\tid=\"metform-wrap-622516b-1152\"\r\n\t\t\tclass=\"mf-form-wrapper\"\r\n\t\t\tdata-form-id=\"1152\"\r\n\t\t\tdata-action=\"https:\/\/dreamlightaba.com\/index.php\/wp-json\/metform\/v1\/entries\/insert\/1152\"\r\n\t\t\tdata-wp-nonce=\"38cfb4c63d\"\r\n\t\t\tdata-form-nonce=\"e171e91b9c\"\r\n\t\t\tdata-quiz-summery = \"false\"\r\n\t\t\tdata-save-progress = \"false\"\r\n\t\t\tdata-form-type=\"general-form\"\r\n\t\t\tdata-stop-vertical-effect=\"\"\r\n\t\t\t><\/div>\r\n\r\n\r\n\t\t<!----------------------------- \r\n\t\t\t* controls_data : find the the props passed indie of data attribute\r\n\t\t\t* props.SubmitResponseMarkup : contains the markup of error or success message\r\n\t\t\t* https:\/\/developer.mozilla.org\/en-US\/docs\/Web\/JavaScript\/Reference\/Template_literals\r\n\t\t--------------------------- -->\r\n\r\n\t\t\t\t<script type=\"text\/mf\" class=\"mf-template\">\r\n\t\t\tfunction controls_data (value){\r\n\t\t\t\tlet currentWrapper = \"mf-response-props-id-1152\";\r\n\t\t\t\tlet currentEl = document.getElementById(currentWrapper);\r\n\t\t\t\t\r\n\t\t\t\treturn currentEl ? currentEl.dataset[value] : false\r\n\t\t\t}\r\n\r\n\r\n\t\t\tlet is_edit_mode = '' ? true : false;\r\n\t\t\tlet message_position = controls_data('messageposition') || 'top';\r\n\r\n\t\t\t\r\n\t\t\tlet message_successIcon = controls_data('successicon') || '';\r\n\t\t\tlet message_errorIcon = controls_data('erroricon') || '';\r\n\t\t\tlet message_editSwitch = controls_data('editswitchopen') === 'yes' ? true : false;\r\n\t\t\tlet message_proClass = controls_data('editswitchopen') === 'yes' ? 'mf_pro_activated' : '';\r\n\t\t\t\r\n\t\t\tlet is_dummy_markup = is_edit_mode && message_editSwitch ? true : false;\r\n\r\n\t\t\t\r\n\t\t\treturn html`\r\n\t\t\t\t<form\r\n\t\t\t\t\tclassName=\"metform-form-content\"\r\n\t\t\t\t\tref=${parent.formContainerRef}\r\n\t\t\t\t\tonSubmit=${ validation.handleSubmit( parent.handleFormSubmit ) }\r\n\t\t\t\t\r\n\t\t\t\t\t>\r\n\t\t\t\r\n\t\t\t\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'top' ?  props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? ' ' :  message_position === 'top' ? props.SubmitResponseMarkup`${parent}${state}${message_successIcon}${message_errorIcon}${message_proClass}` : ''}\r\n\r\n\t\t\t\t\t<!--------------------------------------------------------\r\n\t\t\t\t\t*** IMPORTANT \/ DANGEROUS ***\r\n\t\t\t\t\t${html``} must be used as in immediate child of \"metform-form-main-wrapper\"\r\n\t\t\t\t\tclass otherwise multistep form will not run at all\r\n\t\t\t\t\t---------------------------------------------------------->\r\n\r\n\t\t\t\t\t<div className=\"metform-form-main-wrapper\" key=${'hide-form-after-submit'} ref=${parent.formRef}>\r\n\t\t\t\t\t${html`\r\n\t\t\t\t\t\t\t\t<div data-elementor-type=\"wp-post\" key=\"2\" data-elementor-id=\"1152\" className=\"elementor elementor-1152\" data-elementor-post-type=\"metform-form\">\n\t\t\t\t\t\t<section className=\"elementor-section elementor-top-section elementor-element elementor-element-7eca56f6 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"7eca56f6\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;clouds&quot;,&quot;shape_divider_bottom_negative&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t\t<div className=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div className=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 283.5 27.8\" preserveAspectRatio=\"xMidYMax slice\">\n\t<path className=\"elementor-shape-fill\" d=\"M265.8 3.5c-10.9 0-15.9 6.2-15.9 6.2s-3.6-3.5-9.2-.9c-9.1 4.1-4.4 13.4-4.4 13.4s-1.2.2-1.9.9c-.6.7-.5 1.9-.5 1.9s-1-.5-2.3-.2c-1.3.3-1.6 1.4-1.6 1.4s.4-3.4-1.5-5c-3.9-3.4-8.3-.2-8.3-.2s-.6-.7-.9-.9c-.4-.2-1.2-.2-1.2-.2s-4.4-3.6-11.5-2.6-10.4 7.9-10.4 7.9-.5-3.3-3.9-4.9c-4.8-2.4-7.4 0-7.4 0s2.4-4.1-1.9-6.4-6.2 1.2-6.2 1.2-.9-.5-2.1-.5-2.3 1.1-2.3 1.1.1-.7-1.1-1.1c-1.2-.4-2 0-2 0s3.6-6.8-3.5-8.9c-6-1.8-7.9 2.6-8.4 4-.1-.3-.4-.7-.9-1.1-1-.7-1.3-.5-1.3-.5s1-4-1.7-5.2c-2.7-1.2-4.2 1.1-4.2 1.1s-3.1-1-5.7 1.4-2.1 5.5-2.1 5.5-.9 0-2.1.7-1.4 1.7-1.4 1.7-1.7-1.2-4.3-1.2c-2.6 0-4.5 1.2-4.5 1.2s-.7-1.5-2.8-2.4c-2.1-.9-4 0-4 0s2.6-5.9-4.7-9c-7.3-3.1-12.6 3.3-12.6 3.3s-.9 0-1.9.2c-.9.2-1.5.9-1.5.9S99.4 3 94.9 3.9c-4.5.9-5.7 5.7-5.7 5.7s-2.8-5-12.3-3.9-11.1 6-11.1 6-1.2-1.4-4-.7c-.8.2-1.3.5-1.8.9-.9-2.1-2.7-4.9-6.2-4.4-3.2.4-4 2.2-4 2.2s-.5-.7-1.2-.7h-1.4s-.5-.9-1.7-1.4-2.4 0-2.4 0-2.4-1.2-4.7 0-3.1 4.1-3.1 4.1-1.7-1.4-3.6-.7c-1.9.7-1.9 2.8-1.9 2.8s-.5-.5-1.7-.2c-1.2.2-1.4.7-1.4.7s-.7-2.3-2.8-2.8c-2.1-.5-4.3.2-4.3.2s-1.7-5-11.1-6c-3.8-.4-6.6.2-8.5 1v21.2h283.5V11.1c-.9.2-1.6.4-1.6.4s-5.2-8-16.1-8z\"\/>\n<\/svg>\n\t\t<\/div>\n\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5539f7eb\" data-id=\"5539f7eb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-cc6be4 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"cc6be4\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-8999f43\" data-id=\"8999f43\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-55cb6df elementor-widget elementor-widget-heading\" data-id=\"55cb6df\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">Request Services<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-2518b1f elementor-widget elementor-widget-heading\" data-id=\"2518b1f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">What do we need to get started? <\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-6ced8249 elementor-widget elementor-widget-heading\" data-id=\"6ced8249\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<p className=\"elementor-heading-title elementor-size-default\">A written referral with the child\u2019s diagnosis stating ABA evaluation and treatment is required. \n\n<\/p>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<div className=\"elementor-element elementor-element-500b9439 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"500b9439\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div className=\"elementor-divider\">\n\t\t\t<span className=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-5b469eeb elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"5b469eeb\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-40819b95\" data-id=\"40819b95\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-4dc87cc4 elementor-widget elementor-widget-mf-text\" data-id=\"4dc87cc4\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-4dc87cc4\">\r\n\t\t\t\t\t${ parent.decodeEntities(`First Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-4dc87cc4\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-3b7b6da2\" data-id=\"3b7b6da2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-3b876138 elementor-widget elementor-widget-mf-text\" data-id=\"3b876138\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-last-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-3b876138\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Last Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-3b876138\"\r\n\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-last-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-3a34f48 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"3a34f48\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-5b1958af\" data-id=\"5b1958af\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-8e659bc elementor-widget elementor-widget-mf-text\" data-id=\"8e659bc\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-8e659bc\">\r\n\t\t\t\t\t${ parent.decodeEntities(`DOB`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-8e659bc\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-6d5c64b\" data-id=\"6d5c64b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-74d97fe elementor-widget elementor-widget-mf-select\" data-id=\"74d97fe\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-select&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Male&quot;,&quot;mf_input_option_value&quot;:&quot;Male&quot;,&quot;_id&quot;:&quot;ea07b71&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Female&quot;,&quot;mf_input_option_value&quot;:&quot;Famale&quot;,&quot;_id&quot;:&quot;a18a127&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-select.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t\n\t\t<div className=\"mf-input-wrapper\">\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-select-74d97fe\">\n\t\t\t\t\t${ parent.decodeEntities(`Gender`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\n\t\t\t\t<\/label>\n            \n            <${props.Select}\n                className=${\"mf-input mf-input-select  \" + ( validation.errors['mf-select'] ? 'mf-invalid' : '' )}\n                classNamePrefix=\"mf_select\"\n                name=\"mf-select\"\n                placeholder=\"${ parent.decodeEntities(``) } \"\n                isSearchable=${false}\n                options=${[{\"label\":\"Male\",\"value\":\"Male\",\"isDisabled\":false},{\"label\":\"Female\",\"value\":\"Famale\",\"isDisabled\":false}]}\n                value=${parent.getValue(\"mf-select\") ? [{\"label\":\"Male\",\"value\":\"Male\",\"isDisabled\":false},{\"label\":\"Female\",\"value\":\"Famale\",\"isDisabled\":false}].filter(item => item.value === parent.getValue(\"mf-select\"))[0] : []}\n                onChange=${(e)=> parent.handleSelect(e, \"mf-select\")}\n                ref=${() => {\n\t\t\t\t                    register({ name: \"mf-select\" }, parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false}));\n                    if ( parent.getValue(\"mf-select\") === '' && false ) {\n\t\t\t\t    parent.setValue( 'mf-select', '', true );\n                        parent.handleChange({\n                            target: {\n                                name: 'mf-select',\n                                value: ''\n                            }\n                        });\n                    }\n                }}\n                \/>\n\n            \t\t\t\t<${validation.ErrorMessage}\n\t\t\t\t\terrors=${validation.errors}\n\t\t\t\t\tname=\"mf-select\"\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\n\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-41b886a1\" data-id=\"41b886a1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-79c5af0 elementor-widget elementor-widget-mf-text\" data-id=\"79c5af0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-79c5af0\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Diagnosis`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-79c5af0\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-3656984 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"3656984\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-eafdfb2\" data-id=\"eafdfb2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-2621c1f elementor-widget elementor-widget-mf-text\" data-id=\"2621c1f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-2621c1f\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Current Insurance`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-2621c1f\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-b4db0aa\" data-id=\"b4db0aa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-5e5a9d9 elementor-widget elementor-widget-mf-text\" data-id=\"5e5a9d9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-5e5a9d9\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Primary Care Physician`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-5e5a9d9\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-7c7bd4e elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"7c7bd4e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-05473c7\" data-id=\"05473c7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-7e24ea9 elementor-widget elementor-widget-mf-checkbox\" data-id=\"7e24ea9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-checkbox&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Clinic&quot;,&quot;mf_input_option_value&quot;:&quot;Clinic&quot;,&quot;_id&quot;:&quot;df69d10&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Home&quot;,&quot;mf_input_option_value&quot;:&quot;Home&quot;,&quot;_id&quot;:&quot;5f23a86&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;School\\\/Daycare&quot;,&quot;mf_input_option_value&quot;:&quot;School Day Care&quot;,&quot;_id&quot;:&quot;3467572&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Community&quot;,&quot;mf_input_option_value&quot;:&quot;Community&quot;,&quot;_id&quot;:&quot;92ecfd3&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Other&quot;,&quot;mf_input_option_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;4d12259&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-checkbox.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-checkbox-7e24ea9\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Setting where services will be rendered`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div \r\n\t\t\t\t\t\t\t\t\tref=${el => parent.handleCheckbox(el, 'onLoad')}\r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-checkbox multi-option-input-type\"\r\n\t\t\t\t\tid=\"mf-input-checkbox-7e24ea9\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Clinic\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Clinic`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Home\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Home`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"School Day Care\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`School\/Daycare`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Community\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Community`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Other\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Other`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t<input type=\"hidden\" name=\"mf-checkbox\" value=\"\" \/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-e77a608\" data-id=\"e77a608\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-967b89e elementor-widget elementor-widget-mf-radio\" data-id=\"967b89e\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-radio&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Yes&quot;,&quot;mf_input_option_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;3da25c6&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;No&quot;,&quot;mf_input_option_value&quot;:&quot;No&quot;,&quot;_id&quot;:&quot;1c6b736&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-radio.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\r\n\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-radio-967b89e\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Has the child receive ABA services before?`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-radio multi-option-input-type\" id=\"mf-input-radio-967b89e\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-radio-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\r\n\t\t\t\t\t\t\t\ttype=\"radio\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-radio-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-radio\"\r\n\t\t\t\t\t\t\t\tvalue=\"Yes\"\r\n\t\t\t\t\t\t\t\tdata-checked=\"\"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonChange=${ parent.handleChange }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-radio'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.handleRadioDefault(el);\r\n\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"required\":true}, el)\r\n\t\t\t\t\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\tchecked=${'Yes' === parent.getValue('mf-radio')}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Yes`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-radio-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\r\n\t\t\t\t\t\t\t\ttype=\"radio\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-radio-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-radio\"\r\n\t\t\t\t\t\t\t\tvalue=\"No\"\r\n\t\t\t\t\t\t\t\tdata-checked=\"\"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonChange=${ parent.handleChange }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-radio'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.handleRadioDefault(el);\r\n\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"required\":true}, el)\r\n\t\t\t\t\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\tchecked=${'No' === parent.getValue('mf-radio')}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`No`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-radio\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t\t<input type=\"hidden\" name=\"mf-radio\" value=\"\" \/>\r\n\t\t<\/div>\r\n\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-927afcb elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"927afcb\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-9626ddb\" data-id=\"9626ddb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-7440157 elementor-widget elementor-widget-mf-text\" data-id=\"7440157\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-7440157\">\r\n\t\t\t\t\t${ parent.decodeEntities(`How did you get to know us?`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-7440157\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-4d091a7 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"4d091a7\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-d306785\" data-id=\"d306785\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-752ddb1 elementor-widget elementor-widget-heading\" data-id=\"752ddb1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">Parent\u2019s or Legal Guardian\u2019s Information<\/h3>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-800dac1 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"800dac1\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-5f62cdd\" data-id=\"5f62cdd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-89a5f6a elementor-widget elementor-widget-heading\" data-id=\"89a5f6a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">- Parent\/Guardian 1: <\/h3>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-90b7af5 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"90b7af5\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-f28a899\" data-id=\"f28a899\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-58cf827 elementor-widget elementor-widget-mf-text\" data-id=\"58cf827\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-58cf827\">\r\n\t\t\t\t\t${ parent.decodeEntities(`First Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-58cf827\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-d035390\" data-id=\"d035390\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-a0274af elementor-widget elementor-widget-mf-text\" data-id=\"a0274af\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-last-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-a0274af\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Last Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-a0274af\"\r\n\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-last-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-a58b75d elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"a58b75d\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-5f2530a\" data-id=\"5f2530a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-425e840 elementor-widget elementor-widget-mf-text\" data-id=\"425e840\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-425e840\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Address , City, State, Zip Code`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-425e840\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-aa59373\" data-id=\"aa59373\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-d31d781 elementor-widget elementor-widget-mf-text\" data-id=\"d31d781\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-d31d781\">\r\n\t\t\t\t\t${ parent.decodeEntities(`City`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-d31d781\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-ff52bc7\" data-id=\"ff52bc7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-1b9a693 elementor-widget elementor-widget-mf-text\" data-id=\"1b9a693\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-1b9a693\">\r\n\t\t\t\t\t${ parent.decodeEntities(`State`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-1b9a693\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-18bd01b\" data-id=\"18bd01b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-fd70e9d elementor-widget elementor-widget-mf-text\" data-id=\"fd70e9d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-last-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-fd70e9d\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Zip Code`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-fd70e9d\"\r\n\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-last-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-ff5d9df elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"ff5d9df\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-402f9a1\" data-id=\"402f9a1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-510a82a elementor-widget elementor-widget-mf-number\" data-id=\"510a82a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-number&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-510a82a\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Phone Number`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-510a82a\"\r\n\t\t\t\t\t\t\t\tname=\"mf-number\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-number'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-number\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-fa794cb\" data-id=\"fa794cb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-9179442 elementor-widget elementor-widget-mf-email\" data-id=\"9179442\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-email&quot;}\" data-widget_type=\"mf-email.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-email-9179442\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Email`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input \r\n\t\t\t\ttype=\"email\" \r\n\t\t\t\t \r\n\t\t\t\tdefaultValue=\"\" \r\n\t\t\t\tclassName=\"mf-input \" \r\n\t\t\t\tid=\"mf-input-email-9179442\" \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \" \r\n\t\t\t\t \r\n\t\t\t\tonBlur=${parent.handleChange} onFocus=${parent.handleChange} aria-invalid=${validation.errors['mf-email'] ? 'true' : 'false' } \r\n\t\t\t\tref=${el=> parent.activateValidation({\"message\":\"This field is required.\",\"emailMessage\":\"Please enter a valid Email address\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t<${validation.ErrorMessage} \r\n\t\t\t\terrors=${validation.errors} \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-cd222dd\" data-id=\"cd222dd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-0d10811 elementor-widget elementor-widget-mf-text\" data-id=\"0d10811\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-0d10811\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Marital Status`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-0d10811\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-295eecf4 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"295eecf4\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-3093cfa6\" data-id=\"3093cfa6\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-5558cfe elementor-widget elementor-widget-heading\" data-id=\"5558cfe\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">- Parent\/Guardian 2 (Optional): <\/h3>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-8401947 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"8401947\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-410f352\" data-id=\"410f352\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-57a3680 elementor-widget elementor-widget-mf-text\" data-id=\"57a3680\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-57a3680\">\r\n\t\t\t\t\t${ parent.decodeEntities(`First Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-57a3680\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-bc7faf1\" data-id=\"bc7faf1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-fdda9ba elementor-widget elementor-widget-mf-text\" data-id=\"fdda9ba\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-last-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-fdda9ba\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Last Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-fdda9ba\"\r\n\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-last-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-b8c09bd elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"b8c09bd\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-7afaed3\" data-id=\"7afaed3\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-814cf88 elementor-widget elementor-widget-mf-text\" data-id=\"814cf88\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-814cf88\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Address , City, State, Zip Code`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-814cf88\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-9c2dfcc\" data-id=\"9c2dfcc\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-8450793 elementor-widget elementor-widget-mf-text\" data-id=\"8450793\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-8450793\">\r\n\t\t\t\t\t${ parent.decodeEntities(`City`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-8450793\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-9ef1590\" data-id=\"9ef1590\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-a5bbb77 elementor-widget elementor-widget-mf-text\" data-id=\"a5bbb77\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-a5bbb77\">\r\n\t\t\t\t\t${ parent.decodeEntities(`State`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-a5bbb77\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-38b8b00\" data-id=\"38b8b00\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-4a61fba elementor-widget elementor-widget-mf-text\" data-id=\"4a61fba\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-last-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-4a61fba\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Zip Code`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-4a61fba\"\r\n\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-last-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-c1694ca elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"c1694ca\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-37cb2de\" data-id=\"37cb2de\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-1eceb7d elementor-widget elementor-widget-mf-number\" data-id=\"1eceb7d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-number&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-1eceb7d\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Phone Number`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-1eceb7d\"\r\n\t\t\t\t\t\t\t\tname=\"mf-number\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-number'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-number\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-c8d683c\" data-id=\"c8d683c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-8bf0e4b elementor-widget elementor-widget-mf-email\" data-id=\"8bf0e4b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-email&quot;}\" data-widget_type=\"mf-email.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-email-8bf0e4b\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Email`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input \r\n\t\t\t\ttype=\"email\" \r\n\t\t\t\t \r\n\t\t\t\tdefaultValue=\"\" \r\n\t\t\t\tclassName=\"mf-input \" \r\n\t\t\t\tid=\"mf-input-email-8bf0e4b\" \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \" \r\n\t\t\t\t \r\n\t\t\t\tonBlur=${parent.handleChange} onFocus=${parent.handleChange} aria-invalid=${validation.errors['mf-email'] ? 'true' : 'false' } \r\n\t\t\t\tref=${el=> parent.activateValidation({\"message\":\"This field is required.\",\"emailMessage\":\"Please enter a valid Email address\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t<${validation.ErrorMessage} \r\n\t\t\t\terrors=${validation.errors} \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-2b8e9ed\" data-id=\"2b8e9ed\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-4b3f0dd elementor-widget elementor-widget-mf-text\" data-id=\"4b3f0dd\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-text&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-4b3f0dd\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Marital Status`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-4b3f0dd\"\r\n\t\t\t\tname=\"mf-text\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-text'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-text\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-75474b4 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"75474b4\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-a536add\" data-id=\"a536add\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-79b6d15 elementor-widget elementor-widget-heading\" data-id=\"79b6d15\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">- Attachments <\/h3>\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-ee1f997 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"ee1f997\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-409a7cb\" data-id=\"409a7cb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-2c352e5 elementor-widget elementor-widget-mf-file-upload\" data-id=\"2c352e5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Comprehensive_Diagnostic_Evaluation-upload&quot;}\" data-widget_type=\"mf-file-upload.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-file-upload-2c352e5\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Comprehensive Diagnostic Evaluation (CDE)`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-file-upload-container multi-option-input-type\">\r\n\t\t\t\t<input\r\n\t\t\t\t\ttype=\"file\"\r\n\t\t\t\t\tclassName=\"mf-input mf-input-file-upload \"\r\n\t\t\t\t\tid=\"mf-input-file-upload-2c352e5\" \r\n\t\t\t\t\tname=\"Comprehensive_Diagnostic_Evaluation-upload\" \r\n\t\t\t\t\tmultiple\t\t\t\t\taccept=\".jpg, .jpeg, .png, .pdf, .doc, .docx\"\r\n\t\t\t\t\tonInput=${ parent.handleFileUpload }\r\n\t\t\t\t\taria-invalid=${validation.errors['Comprehensive_Diagnostic_Evaluation-upload'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"required\":true,\"file_types\":[\".jpg\",\".jpeg\",\".png\",\".pdf\",\".doc\",\".docx\"],\"type_message\":\"Invalid file extension\",\"size_limit\":-1,\"limit_message\":\"This field is required.\"}, el) }\r\n\t\t\t\t\t\/>\r\n\t\t\t\t<label htmlFor=\"mf-input-file-upload-2c352e5\" className=\"mf-input-file-upload-label metform-btn\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Choose a file`) } <\/span>\t\t\t\t<\/label>\r\n\t\t\t\t<div className=\"mf-file-name\">\r\n\t\t\t\t\t${\r\n\t\t\t\t\t\t(parent.state.formData['Comprehensive_Diagnostic_Evaluation-upload'] || []).length > 0\r\n\t\t\t\t\t\t? parent.state.formData['Comprehensive_Diagnostic_Evaluation-upload'].map((file, idx) => html`\r\n\t\t\t\t\t\t\t<span className=\"mf-file-name-item\" key=${idx}>\r\n\t\t\t\t\t\t\t\t<span>${file.name}<\/span>\r\n\t\t\t\t\t\t\t\t<span \r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-file-remove\" \r\n\t\t\t\t\t\t\t\t\tonClick=${() => parent.removeUploadedFile('Comprehensive_Diagnostic_Evaluation-upload', idx)}\r\n\t\t\t\t\t\t\t\t\ttitle=\"Remove\"\r\n\t\t\t\t\t\t\t\t>\r\n\t\t\t\t\t\t\t\t\t<label className=\"mf-file-cross\">\u00d7<\/label>\r\n\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t`)\r\n\t\t\t\t\t\t: html`<span>${parent.getFileLabel('Comprehensive_Diagnostic_Evaluation-upload', 'No file chosen.')}<\/span>`\r\n\t\t\t\t\t}\r\n\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Comprehensive_Diagnostic_Evaluation-upload\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\r\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-0f2f6d0\" data-id=\"0f2f6d0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-5e91637 elementor-widget elementor-widget-mf-file-upload\" data-id=\"5e91637\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;ABA_Referral-upload&quot;}\" data-widget_type=\"mf-file-upload.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-file-upload-5e91637\">\r\n\t\t\t\t\t${ parent.decodeEntities(`ABA Referral`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-file-upload-container multi-option-input-type\">\r\n\t\t\t\t<input\r\n\t\t\t\t\ttype=\"file\"\r\n\t\t\t\t\tclassName=\"mf-input mf-input-file-upload \"\r\n\t\t\t\t\tid=\"mf-input-file-upload-5e91637\" \r\n\t\t\t\t\tname=\"ABA_Referral-upload\" \r\n\t\t\t\t\tmultiple\t\t\t\t\taccept=\".jpg, .jpeg, .gif, .png, .pdf, .doc, .docx\"\r\n\t\t\t\t\tonInput=${ parent.handleFileUpload }\r\n\t\t\t\t\taria-invalid=${validation.errors['ABA_Referral-upload'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"required\":true,\"file_types\":[\".jpg\",\".jpeg\",\".gif\",\".png\",\".pdf\",\".doc\",\".docx\"],\"type_message\":\"Invalid file extension\",\"size_limit\":-1,\"limit_message\":\"This field is required.\"}, el) }\r\n\t\t\t\t\t\/>\r\n\t\t\t\t<label htmlFor=\"mf-input-file-upload-5e91637\" className=\"mf-input-file-upload-label metform-btn\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Choose a file`) } <\/span>\t\t\t\t<\/label>\r\n\t\t\t\t<div className=\"mf-file-name\">\r\n\t\t\t\t\t${\r\n\t\t\t\t\t\t(parent.state.formData['ABA_Referral-upload'] || []).length > 0\r\n\t\t\t\t\t\t? parent.state.formData['ABA_Referral-upload'].map((file, idx) => html`\r\n\t\t\t\t\t\t\t<span className=\"mf-file-name-item\" key=${idx}>\r\n\t\t\t\t\t\t\t\t<span>${file.name}<\/span>\r\n\t\t\t\t\t\t\t\t<span \r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-file-remove\" \r\n\t\t\t\t\t\t\t\t\tonClick=${() => parent.removeUploadedFile('ABA_Referral-upload', idx)}\r\n\t\t\t\t\t\t\t\t\ttitle=\"Remove\"\r\n\t\t\t\t\t\t\t\t>\r\n\t\t\t\t\t\t\t\t\t<label className=\"mf-file-cross\">\u00d7<\/label>\r\n\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t`)\r\n\t\t\t\t\t\t: html`<span>${parent.getFileLabel('ABA_Referral-upload', 'No file chosen.')}<\/span>`\r\n\t\t\t\t\t}\r\n\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"ABA_Referral-upload\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-6420220\" data-id=\"6420220\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-58fe942 elementor-widget elementor-widget-mf-file-upload\" data-id=\"58fe942\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-file-upload&quot;}\" data-widget_type=\"mf-file-upload.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-file-upload-58fe942\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Letter of Necessity`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-file-upload-container multi-option-input-type\">\r\n\t\t\t\t<input\r\n\t\t\t\t\ttype=\"file\"\r\n\t\t\t\t\tclassName=\"mf-input mf-input-file-upload \"\r\n\t\t\t\t\tid=\"mf-input-file-upload-58fe942\" \r\n\t\t\t\t\tname=\"mf-file-upload\" \r\n\t\t\t\t\tmultiple\t\t\t\t\taccept=\".jpg, .jpeg, .gif, .png, .pdf, .doc, .docx\"\r\n\t\t\t\t\tonInput=${ parent.handleFileUpload }\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-file-upload'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"required\":false,\"file_types\":[\".jpg\",\".jpeg\",\".gif\",\".png\",\".pdf\",\".doc\",\".docx\"],\"type_message\":\"Invalid file extension\",\"size_limit\":-1,\"limit_message\":\"This field is required.\"}, el) }\r\n\t\t\t\t\t\/>\r\n\t\t\t\t<label htmlFor=\"mf-input-file-upload-58fe942\" className=\"mf-input-file-upload-label metform-btn\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Choose a file`) } <\/span>\t\t\t\t<\/label>\r\n\t\t\t\t<div className=\"mf-file-name\">\r\n\t\t\t\t\t${\r\n\t\t\t\t\t\t(parent.state.formData['mf-file-upload'] || []).length > 0\r\n\t\t\t\t\t\t? parent.state.formData['mf-file-upload'].map((file, idx) => html`\r\n\t\t\t\t\t\t\t<span className=\"mf-file-name-item\" key=${idx}>\r\n\t\t\t\t\t\t\t\t<span>${file.name}<\/span>\r\n\t\t\t\t\t\t\t\t<span \r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-file-remove\" \r\n\t\t\t\t\t\t\t\t\tonClick=${() => parent.removeUploadedFile('mf-file-upload', idx)}\r\n\t\t\t\t\t\t\t\t\ttitle=\"Remove\"\r\n\t\t\t\t\t\t\t\t>\r\n\t\t\t\t\t\t\t\t\t<label className=\"mf-file-cross\">\u00d7<\/label>\r\n\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t`)\r\n\t\t\t\t\t\t: html`<span>${parent.getFileLabel('mf-file-upload', 'No file chosen.')}<\/span>`\r\n\t\t\t\t\t}\r\n\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-file-upload\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-69da788 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"69da788\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-4ec9e5e\" data-id=\"4ec9e5e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-6a974a9 elementor-widget elementor-widget-mf-file-upload\" data-id=\"6a974a9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;IEP-upload&quot;}\" data-widget_type=\"mf-file-upload.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-file-upload-6a974a9\">\r\n\t\t\t\t\t${ parent.decodeEntities(`IEP`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-file-upload-container multi-option-input-type\">\r\n\t\t\t\t<input\r\n\t\t\t\t\ttype=\"file\"\r\n\t\t\t\t\tclassName=\"mf-input mf-input-file-upload \"\r\n\t\t\t\t\tid=\"mf-input-file-upload-6a974a9\" \r\n\t\t\t\t\tname=\"IEP-upload\" \r\n\t\t\t\t\tmultiple\t\t\t\t\taccept=\".jpg, .jpeg, .gif, .png, .pdf, .doc, .docx\"\r\n\t\t\t\t\tonInput=${ parent.handleFileUpload }\r\n\t\t\t\t\taria-invalid=${validation.errors['IEP-upload'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"required\":false,\"file_types\":[\".jpg\",\".jpeg\",\".gif\",\".png\",\".pdf\",\".doc\",\".docx\"],\"type_message\":\"Invalid file extension\",\"size_limit\":-1,\"limit_message\":\"This field is required.\"}, el) }\r\n\t\t\t\t\t\/>\r\n\t\t\t\t<label htmlFor=\"mf-input-file-upload-6a974a9\" className=\"mf-input-file-upload-label metform-btn\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Choose a file`) } <\/span>\t\t\t\t<\/label>\r\n\t\t\t\t<div className=\"mf-file-name\">\r\n\t\t\t\t\t${\r\n\t\t\t\t\t\t(parent.state.formData['IEP-upload'] || []).length > 0\r\n\t\t\t\t\t\t? parent.state.formData['IEP-upload'].map((file, idx) => html`\r\n\t\t\t\t\t\t\t<span className=\"mf-file-name-item\" key=${idx}>\r\n\t\t\t\t\t\t\t\t<span>${file.name}<\/span>\r\n\t\t\t\t\t\t\t\t<span \r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-file-remove\" \r\n\t\t\t\t\t\t\t\t\tonClick=${() => parent.removeUploadedFile('IEP-upload', idx)}\r\n\t\t\t\t\t\t\t\t\ttitle=\"Remove\"\r\n\t\t\t\t\t\t\t\t>\r\n\t\t\t\t\t\t\t\t\t<label className=\"mf-file-cross\">\u00d7<\/label>\r\n\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t`)\r\n\t\t\t\t\t\t: html`<span>${parent.getFileLabel('IEP-upload', 'No file chosen.')}<\/span>`\r\n\t\t\t\t\t}\r\n\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"IEP-upload\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-359e3c2\" data-id=\"359e3c2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-a2ff2f5 elementor-widget elementor-widget-mf-file-upload\" data-id=\"a2ff2f5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Insurance_Card-upload&quot;}\" data-widget_type=\"mf-file-upload.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-file-upload-a2ff2f5\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Insurance Card`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-file-upload-container multi-option-input-type\">\r\n\t\t\t\t<input\r\n\t\t\t\t\ttype=\"file\"\r\n\t\t\t\t\tclassName=\"mf-input mf-input-file-upload \"\r\n\t\t\t\t\tid=\"mf-input-file-upload-a2ff2f5\" \r\n\t\t\t\t\tname=\"Insurance_Card-upload\" \r\n\t\t\t\t\tmultiple\t\t\t\t\taccept=\".jpg, .jpeg, .gif, .png, .pdf, .doc, .docx\"\r\n\t\t\t\t\tonInput=${ parent.handleFileUpload }\r\n\t\t\t\t\taria-invalid=${validation.errors['Insurance_Card-upload'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"required\":true,\"file_types\":[\".jpg\",\".jpeg\",\".gif\",\".png\",\".pdf\",\".doc\",\".docx\"],\"type_message\":\"Invalid file extension\",\"size_limit\":-1,\"limit_message\":\"This field is required.\"}, el) }\r\n\t\t\t\t\t\/>\r\n\t\t\t\t<label htmlFor=\"mf-input-file-upload-a2ff2f5\" className=\"mf-input-file-upload-label metform-btn\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Choose a file`) } <\/span>\t\t\t\t<\/label>\r\n\t\t\t\t<div className=\"mf-file-name\">\r\n\t\t\t\t\t${\r\n\t\t\t\t\t\t(parent.state.formData['Insurance_Card-upload'] || []).length > 0\r\n\t\t\t\t\t\t? parent.state.formData['Insurance_Card-upload'].map((file, idx) => html`\r\n\t\t\t\t\t\t\t<span className=\"mf-file-name-item\" key=${idx}>\r\n\t\t\t\t\t\t\t\t<span>${file.name}<\/span>\r\n\t\t\t\t\t\t\t\t<span \r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-file-remove\" \r\n\t\t\t\t\t\t\t\t\tonClick=${() => parent.removeUploadedFile('Insurance_Card-upload', idx)}\r\n\t\t\t\t\t\t\t\t\ttitle=\"Remove\"\r\n\t\t\t\t\t\t\t\t>\r\n\t\t\t\t\t\t\t\t\t<label className=\"mf-file-cross\">\u00d7<\/label>\r\n\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t`)\r\n\t\t\t\t\t\t: html`<span>${parent.getFileLabel('Insurance_Card-upload', 'No file chosen.')}<\/span>`\r\n\t\t\t\t\t}\r\n\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Insurance_Card-upload\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\r\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-d0154e9\" data-id=\"d0154e9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-c09ea0b elementor-widget elementor-widget-mf-file-upload\" data-id=\"c09ea0b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Discharge_Form-upload&quot;}\" data-widget_type=\"mf-file-upload.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-file-upload-c09ea0b\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Discharge Form`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-file-upload-container multi-option-input-type\">\r\n\t\t\t\t<input\r\n\t\t\t\t\ttype=\"file\"\r\n\t\t\t\t\tclassName=\"mf-input mf-input-file-upload \"\r\n\t\t\t\t\tid=\"mf-input-file-upload-c09ea0b\" \r\n\t\t\t\t\tname=\"Discharge_Form-upload\" \r\n\t\t\t\t\tmultiple\t\t\t\t\taccept=\".jpg, .jpeg, .gif, .png, .pdf, .doc, .docx\"\r\n\t\t\t\t\tonInput=${ parent.handleFileUpload }\r\n\t\t\t\t\taria-invalid=${validation.errors['Discharge_Form-upload'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"required\":false,\"file_types\":[\".jpg\",\".jpeg\",\".gif\",\".png\",\".pdf\",\".doc\",\".docx\"],\"type_message\":\"Invalid file extension\",\"size_limit\":-1,\"limit_message\":\"This field is required.\"}, el) }\r\n\t\t\t\t\t\/>\r\n\t\t\t\t<label htmlFor=\"mf-input-file-upload-c09ea0b\" className=\"mf-input-file-upload-label metform-btn\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Choose a file`) } <\/span>\t\t\t\t<\/label>\r\n\t\t\t\t<div className=\"mf-file-name\">\r\n\t\t\t\t\t${\r\n\t\t\t\t\t\t(parent.state.formData['Discharge_Form-upload'] || []).length > 0\r\n\t\t\t\t\t\t? parent.state.formData['Discharge_Form-upload'].map((file, idx) => html`\r\n\t\t\t\t\t\t\t<span className=\"mf-file-name-item\" key=${idx}>\r\n\t\t\t\t\t\t\t\t<span>${file.name}<\/span>\r\n\t\t\t\t\t\t\t\t<span \r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-file-remove\" \r\n\t\t\t\t\t\t\t\t\tonClick=${() => parent.removeUploadedFile('Discharge_Form-upload', idx)}\r\n\t\t\t\t\t\t\t\t\ttitle=\"Remove\"\r\n\t\t\t\t\t\t\t\t>\r\n\t\t\t\t\t\t\t\t\t<label className=\"mf-file-cross\">\u00d7<\/label>\r\n\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t`)\r\n\t\t\t\t\t\t: html`<span>${parent.getFileLabel('Discharge_Form-upload', 'No file chosen.')}<\/span>`\r\n\t\t\t\t\t}\r\n\t\t\t\t<\/div>\r\n\t\t\t\t\r\n\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Discharge_Form-upload\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t<span className=\"mf-input-help\"> ${ parent.decodeEntities(`(applicable if receiving services from another aba provider)`) }  <\/span>\t\t<\/div>\r\n\r\n\t\t\r\n\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<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-99c7b50 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"99c7b50\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-2afaea7\" data-id=\"2afaea7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-f1f7c9a\" data-id=\"f1f7c9a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-3740643\" data-id=\"3740643\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-360801a elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"360801a\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-86a6f64\" data-id=\"86a6f64\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-bf61036\" data-id=\"bf61036\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-5e59a2f mf-btn--center elementor-widget elementor-widget-mf-button\" data-id=\"5e59a2f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"mf-button.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div className=\"mf-btn-wraper \" data-mf-form-conditional-logic-requirement=\"\">\r\n\t\t\t\t\t\t\t<button type=\"submit\" className=\"metform-btn metform-submit-btn \" id=\"\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`SEND REQUEST SERVICES`) } <\/span>\r\n\t\t\t\t<\/button>\r\n\t\t\t        <\/div>\r\n        \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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-c25aefe\" data-id=\"c25aefe\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t<div className=\"elementor-element elementor-element-52880e1 e-flex e-con-boxed e-con e-parent\" data-id=\"52880e1\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-ba04412 elementor-widget elementor-widget-mf-email\" data-id=\"ba04412\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-email&quot;}\" data-widget_type=\"mf-email.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-email-ba04412\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Email`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input \r\n\t\t\t\ttype=\"email\" \r\n\t\t\t\t \r\n\t\t\t\tdefaultValue=\"\" \r\n\t\t\t\tclassName=\"mf-input \" \r\n\t\t\t\tid=\"mf-input-email-ba04412\" \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Email`) } \" \r\n\t\t\t\t \r\n\t\t\t\tonBlur=${parent.handleChange} onFocus=${parent.handleChange} aria-invalid=${validation.errors['mf-email'] ? 'true' : 'false' } \r\n\t\t\t\tref=${el=> parent.activateValidation({\"message\":\"This field is required.\",\"emailMessage\":\"Please enter a valid Email address\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t<${validation.ErrorMessage} \r\n\t\t\t\terrors=${validation.errors} \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t`}\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'bottom' ? props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? ' ' : message_position === 'bottom' ? props.SubmitResponseMarkup`${parent}${state}${message_successIcon}${message_errorIcon}${message_proClass}` : ''}\r\n\t\t\t\t\r\n\t\t\t\t<\/form>\r\n\t\t\t`\r\n\t\t<\/script>\r\n\r\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1102f211 elementor-widget__width-auto elementor-absolute elementor-hidden-tablet elementor-hidden-mobile elementor-invisible elementor-widget elementor-widget-image\" data-id=\"1102f211\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;,&quot;_animation&quot;:&quot;lightSpeedIn&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"27\" height=\"27\" src=\"https:\/\/dreamlightaba.com\/wp-content\/uploads\/2025\/04\/particles-9.png\" class=\"attachment-full size-full wp-image-46\" alt=\"\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-45987536 elementor-widget__width-auto elementor-absolute elementor-hidden-tablet elementor-hidden-mobile elementor-invisible elementor-widget elementor-widget-image\" data-id=\"45987536\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;,&quot;_animation&quot;:&quot;rotateIn&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"81\" height=\"83\" src=\"https:\/\/dreamlightaba.com\/wp-content\/uploads\/2025\/04\/particles-1.png\" class=\"attachment-full size-full wp-image-22\" alt=\"\" \/>\t\t\t\t\t\t\t\t\t\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<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Request Services<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-2131","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/pages\/2131","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/comments?post=2131"}],"version-history":[{"count":7,"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/pages\/2131\/revisions"}],"predecessor-version":[{"id":2140,"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/pages\/2131\/revisions\/2140"}],"wp:attachment":[{"href":"https:\/\/dreamlightaba.com\/index.php\/wp-json\/wp\/v2\/media?parent=2131"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}