{"id":11,"date":"2025-11-13T12:06:30","date_gmt":"2025-11-13T12:06:30","guid":{"rendered":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/refer-us\/"},"modified":"2025-11-13T12:37:12","modified_gmt":"2025-11-13T12:37:12","slug":"refer-us","status":"publish","type":"page","link":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/refer-us\/","title":{"rendered":"Refer Us"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"11\" class=\"elementor elementor-11\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9c89fcf e-flex e-con-boxed e-con e-parent\" data-id=\"9c89fcf\" 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<div class=\"elementor-element elementor-element-7b6ade0d e-con-full e-flex e-con e-child\" data-id=\"7b6ade0d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5503837c elementor-widget elementor-widget-heading\" data-id=\"5503837c\" 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 Patient, Client, or Resident<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7a92eed elementor-widget elementor-widget-text-editor\" data-id=\"7a92eed\" 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>Simply fill out the form below, and one of our state representatives will reach out to you within 24 hours!<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8ee3d01 elementor-alert-info elementor-widget elementor-widget-alert\" data-id=\"8ee3d01\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"alert.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-alert\" role=\"alert\">\n\n\t\t\t\t\t\t<span class=\"elementor-alert-title\">Note:<\/span>\n\t\t\t\n\t\t\t\t\t\t<span class=\"elementor-alert-description\">This form is fully customizable and seamlessly integrates with major CRMs, Google Docs, and more for automated data transfer. For your convenience, form fields are currently set as optional, allowing you to easily navigate through all steps without completing the form.<\/br>\n<b>Optional features: <\/b>Price calculation, payment collection, eSign, PDF Export, Recurring payment collections, etc. <\/span>\n\t\t\t\n\t\t\t\t\t\t<button type=\"button\" class=\"elementor-alert-dismiss\" aria-label=\"Dismiss this alert.\">\n\t\t\t\t\t\t\t\t\t<span aria-hidden=\"true\">&times;<\/span>\n\t\t\t\t\t\t\t<\/button>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-19bed1c1 ha-has-bg-overlay elementor-widget elementor-widget-shortcode\" data-id=\"19bed1c1\" 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-146 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-146\" data-uid=\"6a202c734fba5\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-146\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-146 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=\"146\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a202c734fba5\"\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_6a202c734fba5\" id=\"forminator-field-name-1_6a202c734fba5-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_6a202c734fba5\" 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_6a202c734fba5\" id=\"forminator-field-email-1_6a202c734fba5-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_6a202c734fba5\" 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_6a202c734fba5\" id=\"forminator-field-phone-1_6a202c734fba5-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_6a202c734fba5\" 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_6a202c734fba5\" id=\"forminator-field-text-1_6a202c734fba5-label\" class=\"forminator-label\">Organization<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a202c734fba5\" 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-146__field--select-1_6a202c734fba5\" id=\"forminator-form-146__field--select-1_6a202c734fba5-label\" class=\"forminator-label\">Who should we contact?<\/label><select  id=\"forminator-form-146__field--select-1_6a202c734fba5\" 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-146__field--select-1_6a202c734fba5-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_6a202c734fba5\" id=\"forminator-field-text-2_6a202c734fba5-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_6a202c734fba5\" 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_6a202c734fba5\" id=\"forminator-field-phone-2_6a202c734fba5-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_6a202c734fba5\" 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_6a202c734fba5\" id=\"forminator-field-email-2_6a202c734fba5-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_6a202c734fba5\" 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_6a202c734fba5\" id=\"forminator-field-text-3_6a202c734fba5-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_6a202c734fba5\" 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=\"599d32fdd3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/11\" \/><input type=\"hidden\" name=\"form_id\" value=\"146\"><input type=\"hidden\" name=\"page_id\" value=\"11\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/refer-us\/\"><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<div class=\"elementor-element elementor-element-4139da45 e-con-full e-flex e-con e-child\" data-id=\"4139da45\" 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-3bb7dab elementor-widget elementor-widget-heading\" data-id=\"3bb7dab\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">What happens next?\n\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5e932782 elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"5e932782\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-check-circle\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 48c110.532 0 200 89.451 200 200 0 110.532-89.451 200-200 200-110.532 0-200-89.451-200-200 0-110.532 89.451-200 200-200m140.204 130.267l-22.536-22.718c-4.667-4.705-12.265-4.736-16.97-.068L215.346 303.697l-59.792-60.277c-4.667-4.705-12.265-4.736-16.97-.069l-22.719 22.536c-4.705 4.667-4.736 12.265-.068 16.971l90.781 91.516c4.667 4.705 12.265 4.736 16.97.068l172.589-171.204c4.704-4.668 4.734-12.266.067-16.971z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">A dedicated Emerest representative will contact you within 24 hours.<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-check-circle\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 48c110.532 0 200 89.451 200 200 0 110.532-89.451 200-200 200-110.532 0-200-89.451-200-200 0-110.532 89.451-200 200-200m140.204 130.267l-22.536-22.718c-4.667-4.705-12.265-4.736-16.97-.068L215.346 303.697l-59.792-60.277c-4.667-4.705-12.265-4.736-16.97-.069l-22.719 22.536c-4.705 4.667-4.736 12.265-.068 16.971l90.781 91.516c4.667 4.705 12.265 4.736 16.97.068l172.589-171.204c4.704-4.668 4.734-12.266.067-16.971z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">We will discuss your needs.<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-check-circle\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 48c110.532 0 200 89.451 200 200 0 110.532-89.451 200-200 200-110.532 0-200-89.451-200-200 0-110.532 89.451-200 200-200m140.204 130.267l-22.536-22.718c-4.667-4.705-12.265-4.736-16.97-.068L215.346 303.697l-59.792-60.277c-4.667-4.705-12.265-4.736-16.97-.069l-22.719 22.536c-4.705 4.667-4.736 12.265-.068 16.971l90.781 91.516c4.667 4.705 12.265 4.736 16.97.068l172.589-171.204c4.704-4.668 4.734-12.266.067-16.971z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">We will select the best options for you based on your needs.<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\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 Patient, Client, or Resident Simply fill out the form below, and one of our state representatives will reach out to you within 24 hours! Note: This form is fully customizable and seamlessly integrates with major CRMs, Google Docs, and more for automated data transfer. For your convenience, form fields are currently set as [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-11","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/11","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/comments?post=11"}],"version-history":[{"count":5,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/11\/revisions"}],"predecessor-version":[{"id":156,"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/pages\/11\/revisions\/156"}],"wp:attachment":[{"href":"https:\/\/webdesigntemplates.net\/for-private-duty-caregivers\/wp-json\/wp\/v2\/media?parent=11"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}