{"id":1114,"date":"2023-11-03T00:39:31","date_gmt":"2023-11-03T00:39:31","guid":{"rendered":"https:\/\/arkprovidence.com.au\/?page_id=1114"},"modified":"2023-11-03T01:30:59","modified_gmt":"2023-11-03T01:30:59","slug":"request-for-services-form","status":"publish","type":"page","link":"https:\/\/arkprovidence.com.au\/index.php\/request-for-services-form\/","title":{"rendered":"REQUEST FOR SERVICES FORM"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1114\" class=\"elementor elementor-1114\">\n\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1788947 e-flex e-con-boxed e-con e-parent\" data-id=\"1788947\" data-element_type=\"container\" data-settings=\"{&quot;content_width&quot;:&quot;boxed&quot;}\" data-core-v316-plus=\"true\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-158ce94 fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"158ce94\" data-element_type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_4'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Request for Services Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='1114' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"dd09522902\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/1114\" \/><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Are you making a complaint or providing feedback on someone&#039;s behalf? *\">Are you making a complaint or providing feedback on someone's behalf? *<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for=input_radio_794d9062daf6cb870896e490cda0c164><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"yes\"  id='input_radio_794d9062daf6cb870896e490cda0c164' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_adb14216d167ad32794d40812515855a><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_adb14216d167ad32794d40812515855a' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text' aria-label=\"PERSONAL DETAILS OF CLIENT\/PARTICPANT\">PERSONAL DETAILS OF CLIENT\/PARTICPANT<\/label><div class=\"ff-el-tooltip\" data-content=\"Details of f the Client\/Participant the Complaint or Feedback is about\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" placeholder=\"Client's Name\" data-name=\"input_text\" id=\"ff_4_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" placeholder=\"Client's Address\" data-name=\"input_text_1\" id=\"ff_4_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" placeholder=\"Client's Phone\" data-name=\"input_text_2\" id=\"ff_4_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" placeholder=\"Client's Email\" data-name=\"input_text_3\" id=\"ff_4_input_text_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Radio Field\">Radio Field<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_1_36c69fa15d32f9f169c4857f45af3856><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_1_36c69fa15d32f9f169c4857f45af3856' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_1_a6781daa06a41aab9daa4449dab87b8e><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_1_a6781daa06a41aab9daa4449dab87b8e' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime' aria-label=\"Date \/ Time\">Date \/ Time<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_4_datetime\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"d\/m\/Y- (Ex: 28\/04\/2023)\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_datetime_1' aria-label=\"Date \/ Time\">Date \/ Time<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_1\" id=\"ff_4_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Checkbox Field\">Checkbox Field<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5bb86021737cce2a5c885e065a2f76ab><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Can we call you?\"  id='checkbox_5bb86021737cce2a5c885e065a2f76ab' aria-label='Can we call you?' aria-invalid='false' aria-required=false> <span>Can we call you?<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_dropdown' aria-label=\"Best Time to Call\">Best Time to Call<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_4_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Select -<\/option><option value=\"Morning\"  selected>Morning<\/option><option value=\"Afternoon\"  >Afternoon<\/option><option value=\"Evening\"  >Evening<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_4' aria-label=\"MEDICAL NOTES\">MEDICAL NOTES<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" placeholder=\"Primary Disability:\" data-name=\"input_text_4\" id=\"ff_4_input_text_4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" placeholder=\"Secondary Disability:\" data-name=\"input_text_5\" id=\"ff_4_input_text_5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" placeholder=\"Psychosocial Disability:\" data-name=\"input_text_6\" id=\"ff_4_input_text_6\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" placeholder=\"Medical Conditions:\" data-name=\"input_text_8\" id=\"ff_4_input_text_8\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" placeholder=\"Allergies\" data-name=\"input_text_7\" id=\"ff_4_input_text_7\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_9' aria-label=\"MEDICAL NOTES : Doctor&#039;s Details\">MEDICAL NOTES : Doctor's Details<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" placeholder=\"Doctors Name:\" data-name=\"input_text_9\" id=\"ff_4_input_text_9\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"Drs Phone or mobile Number:\" data-name=\"input_text_10\" id=\"ff_4_input_text_10\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" placeholder=\"Drs Email:\" data-name=\"input_text_11\" id=\"ff_4_input_text_11\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" placeholder=\"Practice Address\" data-name=\"input_text_12\" id=\"ff_4_input_text_12\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"ADDITIONAL CONTACTS\">ADDITIONAL CONTACTS<\/label><div class=\"ff-el-tooltip\" data-content=\"Do you want to list any additional contacts?\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_ce516e756ff5136d6c48c02485bbed6e><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_2_ce516e756ff5136d6c48c02485bbed6e' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_609fe1de99e9d3bf815fc4a43e606f82><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_2_609fe1de99e9d3bf815fc4a43e606f82' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_13' aria-label=\"Relationship to participant: Copy\">Relationship to participant: Copy<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" placeholder=\"e.g. Parent or Legal Guardian\" data-name=\"input_text_13\" id=\"ff_4_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Assistance, Culture, Medication and Education\">Assistance, Culture, Medication and Education<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_910d6d2cee615a3e7f3e0fab770f65b5><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Aboriginal\"  id='checkbox_1_910d6d2cee615a3e7f3e0fab770f65b5' aria-label='Aboriginal' aria-invalid='false' aria-required=false> <span>Aboriginal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_059a5ceec10c3793b661f4cd5ecf9625><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"TSI\"  id='checkbox_1_059a5ceec10c3793b661f4cd5ecf9625' aria-label='TSI' aria-invalid='false' aria-required=false> <span>TSI<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_ad03c5811e6aa2e6ba3435cb7975b39f><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"CALD\"  id='checkbox_1_ad03c5811e6aa2e6ba3435cb7975b39f' aria-label='CALD' aria-invalid='false' aria-required=false> <span>CALD<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Is English your primary language at home\">Is English your primary language at home<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_374b08d0b9f4c85fece9fa275bd9bbec><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_3_374b08d0b9f4c85fece9fa275bd9bbec' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_1cb7b20e1d9582ec1d62acb567309818><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3_1cb7b20e1d9582ec1d62acb567309818' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Do you require an Interpreter\">Do you require an Interpreter<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_151ef9c0f34935f5fa56c01dbfccdbd6><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_4_151ef9c0f34935f5fa56c01dbfccdbd6' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_8b9f821b8dc192fc856e54125d758d18><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_4_8b9f821b8dc192fc856e54125d758d18' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_14' aria-label=\"Please tell us of any communication methods you use\">Please tell us of any communication methods you use<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" placeholder=\"e.g. Ausian\" data-name=\"input_text_14\" id=\"ff_4_input_text_14\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Do you need transportation assistance?\">Do you need transportation assistance?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_286f7c091d53124973d0c6205b31993a><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_5_286f7c091d53124973d0c6205b31993a' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_5ee511c099c393dc596dab4bc194194f><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_5_5ee511c099c393dc596dab4bc194194f' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Do you need assistance from Ark Providence staff with taking medication(s)\">Do you need assistance from Ark Providence staff with taking medication(s)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_3086168a660a74f3677575b6b6f944cf><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_6_3086168a660a74f3677575b6b6f944cf' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_d2c75122e86c5732a75c9fee1a9c49f1><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_6_d2c75122e86c5732a75c9fee1a9c49f1' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Do you need assistance from Ark Providence staff with eating and drinking?(s)\">Do you need assistance from Ark Providence staff with eating and drinking?(s)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_82c7a035f0d8d8a677b7f37006c70855><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_7_82c7a035f0d8d8a677b7f37006c70855' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_e3b5c4ab4db2c7dbd7579e4e90f6f30b><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_7_e3b5c4ab4db2c7dbd7579e4e90f6f30b' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Do you need assistance with personal care?\">Do you need assistance with personal care?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_8_7e28c3ec0569bc07d9e63d205e63b51f><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_8_7e28c3ec0569bc07d9e63d205e63b51f' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_8_2f3d2e6ee1a1ce7a7bef744574dc7028><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_8_2f3d2e6ee1a1ce7a7bef744574dc7028' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Are there any health issues that we should be aware of like Epilepsy, diabetes, etc.?\">Are there any health issues that we should be aware of like Epilepsy, diabetes, etc.?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_9_a65af637c774e26ac8705ea66bd532c1><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_9_a65af637c774e26ac8705ea66bd532c1' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_9_f47851ed6ff21f5998168c02a009ce72><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  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complaint or providing feedback on someone&#8217;s behalf? * Yes No PERSONAL DETAILS OF CLIENT\/PARTICPANTRadio Field Yes NoDate \/ TimeDate \/ TimeCheckbox Field Can we call you?Best Time to Call&#8211; Select &#8211;MorningAfternoonEveningMEDICAL NOTESMEDICAL NOTES : Doctor&#8217;s DetailsADDITIONAL CONTACTS Yes NoRelationship to participant: CopyAssistance, Culture, Medication and Education Aboriginal &hellip;<\/p>\n<p class=\"read-more\"> <a class=\"\" href=\"https:\/\/arkprovidence.com.au\/index.php\/request-for-services-form\/\"> <span class=\"screen-reader-text\">REQUEST FOR SERVICES FORM<\/span> Read More &raquo;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","footnotes":""},"_links":{"self":[{"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1114"}],"collection":[{"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/comments?post=1114"}],"version-history":[{"count":4,"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1114\/revisions"}],"predecessor-version":[{"id":1131,"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/pages\/1114\/revisions\/1131"}],"wp:attachment":[{"href":"https:\/\/arkprovidence.com.au\/index.php\/wp-json\/wp\/v2\/media?parent=1114"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}