{"id":168,"date":"2025-11-13T08:33:35","date_gmt":"2025-11-13T08:33:35","guid":{"rendered":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/?page_id=168"},"modified":"2025-11-13T08:34:39","modified_gmt":"2025-11-13T08:34:39","slug":"send-a-referral","status":"publish","type":"page","link":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/send-a-referral\/","title":{"rendered":"Send a Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"168\" class=\"elementor elementor-168\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f0be47e e-flex e-con-boxed e-con e-parent\" data-id=\"f0be47e\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6ce0d65 elementor-widget elementor-widget-heading\" data-id=\"6ce0d65\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Refer a Family, Change a Life<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0688393 elementor-widget elementor-widget-text-editor\" data-id=\"0688393\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Trusted In-Home Care for Your Loved Ones<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-fc6d2df e-flex e-con-boxed e-con e-parent\" data-id=\"fc6d2df\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-f7eb014 e-con-full e-flex e-con e-child\" data-id=\"f7eb014\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-60d580d elementor-widget elementor-widget-shortcode\" data-id=\"60d580d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-135 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-135\" data-uid=\"69d37772120cd\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-135\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-135 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"135\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69d37772120cd\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69d37772120cd\" id=\"forminator-field-name-1_69d37772120cd-label\" class=\"forminator-label\">Your Full Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69d37772120cd\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69d37772120cd\" id=\"forminator-field-email-1_69d37772120cd-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_69d37772120cd\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69d37772120cd\" id=\"forminator-field-phone-1_69d37772120cd-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-1_69d37772120cd\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69d37772120cd\" id=\"forminator-field-text-1_69d37772120cd-label\" class=\"forminator-label\">Organization<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69d37772120cd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-135__field--select-1_69d37772120cd\" id=\"forminator-form-135__field--select-1_69d37772120cd-label\" class=\"forminator-label\">Who should we contact?<\/label><select  id=\"forminator-form-135__field--select-1_69d37772120cd\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"- Select -\" data-search=\"false\" data-search-placeholder=\"- Select -\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-135__field--select-1_69d37772120cd-label\"><option value=\"\"  >- Select -<\/option><option value=\"one\"  data-calculation=\"0\">Contact me<\/option><option value=\"two\"  data-calculation=\"0\">Contact client\/patient\/resident<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Patient Info<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69d37772120cd\" id=\"forminator-field-text-2_69d37772120cd-label\" class=\"forminator-label\">Client\/Patient\/Resident Name* <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69d37772120cd\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69d37772120cd\" id=\"forminator-field-phone-2_69d37772120cd-label\" class=\"forminator-label\">Client\/Patient\/Resident Phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-2_69d37772120cd\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69d37772120cd\" id=\"forminator-field-email-2_69d37772120cd-label\" class=\"forminator-label\">Client\/Patient\/Resident Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-2_69d37772120cd\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69d37772120cd\" id=\"forminator-field-text-3_69d37772120cd-label\" class=\"forminator-label\">Client\/Patient\/Resident Zip Code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69d37772120cd\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"79ef479af1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/for-private-duty-care\/wp-json\/wp\/v2\/pages\/168\" \/><input type=\"hidden\" name=\"form_id\" value=\"135\"><input type=\"hidden\" name=\"page_id\" value=\"168\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/webdesigntemplates.net\/for-private-duty-care\/send-a-referral\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\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","protected":false},"excerpt":{"rendered":"<p>Refer a Family, Change a Life Trusted In-Home Care for Your Loved Ones<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-168","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/pages\/168","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/comments?post=168"}],"version-history":[{"count":4,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/pages\/168\/revisions"}],"predecessor-version":[{"id":172,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/pages\/168\/revisions\/172"}],"wp:attachment":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-care\/wp-json\/wp\/v2\/media?parent=168"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}