{"id":473,"date":"2026-02-01T19:25:51","date_gmt":"2026-02-01T19:25:51","guid":{"rendered":"https:\/\/wpdev.billychandler.com\/nrmr\/?page_id=473"},"modified":"2026-05-10T13:31:48","modified_gmt":"2026-05-10T13:31:48","slug":"consent-to-exchange-application","status":"publish","type":"page","link":"https:\/\/wpdev.billychandler.com\/nrmr\/applications\/consent-to-exchange-application\/","title":{"rendered":"Consent to Exchange Application"},"content":{"rendered":"<div class='fluentform ff-default fluentform_wrapper_6 ffs_default_wrap'><form data-form_id=\"6\" id=\"fluentform_6\" class=\"frm-fluent-form fluent_form_6 ff-el-form-top ff_form_instance_6_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_6_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;\">Consent to Exchange Information<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='473' \/><input type=\"hidden\" id=\"_fluentform_6_fluentformnonce\" name=\"_fluentform_6_fluentformnonce\" value=\"a8970a2dd5\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/nrmr\/wp-json\/wp\/v2\/pages\/473\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-6_1\" ><p><em>I understand that different agencies provide different services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so they work together effectively to provide or coordinate these services or benefits.<\/em><\/p><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text' id='label_ff_6_input_text' aria-label=\"Client Name\">Client Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_6_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text_1' id='label_ff_6_input_text_1' aria-label=\"Last 4 Digits of SSN\">Last 4 Digits of SSN<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_6_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff_list_2col'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Information Exchange Consent\">Information Exchange Consent<\/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_a527f4f9b120ad030eabd8f8780b4f3c'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Assessment Information\"  id='checkbox_a527f4f9b120ad030eabd8f8780b4f3c' aria-label='Assessment Information' aria-invalid='false' aria-required=false> <span>Assessment Information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_b245fdfded23dd2ad21b15f770649c58'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Benefits\/Services Needed\"  id='checkbox_b245fdfded23dd2ad21b15f770649c58' aria-label='Benefits\/Services Needed' aria-invalid='false' aria-required=false> <span>Benefits\/Services Needed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_9d1a86519b72a28ac4b1bc1e11433e8c'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Criminal Justice Records\"  id='checkbox_9d1a86519b72a28ac4b1bc1e11433e8c' aria-label='Criminal Justice Records' aria-invalid='false' aria-required=false> <span>Criminal Justice Records<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4367655ac894cb9c5b585b9d07cee227'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Educational Records\"  id='checkbox_4367655ac894cb9c5b585b9d07cee227' aria-label='Educational Records' aria-invalid='false' aria-required=false> <span>Educational Records<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_680d0215fc63370b17d2566a03e5251c'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Employment Records\"  id='checkbox_680d0215fc63370b17d2566a03e5251c' aria-label='Employment Records' aria-invalid='false' aria-required=false> <span>Employment Records<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_20af1f68fe810fbdc3a0c54d9f4077a8'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Financial Information\"  id='checkbox_20af1f68fe810fbdc3a0c54d9f4077a8' aria-label='Financial Information' aria-invalid='false' aria-required=false> <span>Financial Information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_64de9ce8d51e3a481840110e1a1d8c0d'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Medical Diagnosis\"  id='checkbox_64de9ce8d51e3a481840110e1a1d8c0d' aria-label='Medical Diagnosis' aria-invalid='false' aria-required=false> <span>Medical Diagnosis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8d443f26be6c399f4bedd0d474853c99'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mental Health Diagnosis\"  id='checkbox_8d443f26be6c399f4bedd0d474853c99' aria-label='Mental Health Diagnosis' aria-invalid='false' aria-required=false> <span>Mental Health Diagnosis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_aa7ccfc6392203782fd63478ca4506af'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Follow-up Employment Vertification\"  id='checkbox_aa7ccfc6392203782fd63478ca4506af' aria-label='Follow-up Employment Vertification' aria-invalid='false' aria-required=false> <span>Follow-up Employment Vertification<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1e563582d24841022f3b6d024095a282'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other (specify below)\"  id='checkbox_1e563582d24841022f3b6d024095a282' aria-label='Other (specify below)' aria-invalid='false' aria-required=false> <span>Other (specify below)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_2' id='label_ff_6_input_text_2' aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_6_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-6_2\" ><p>I consent that the following information can be exchanged. Check the documents you consent to be shared with partnering agencies:<\/p><\/div><div class='ff-el-group  ff_list_2col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"I want the following agencies to be able to exchange the information selected above\">I want the following agencies to be able to exchange the information selected above<\/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_ea2b5cd6fb07dc188a2a23af27670e42'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"New River\/Mount Rogers Workforce Development Board\"  id='checkbox_1_ea2b5cd6fb07dc188a2a23af27670e42' aria-label='New River\/Mount Rogers Workforce Development Board' aria-invalid='false' aria-required=true> <span>New River\/Mount Rogers Workforce Development Board<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_a993ffeda21a745667048bd7112104b5'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"People Incorporated\"  id='checkbox_1_a993ffeda21a745667048bd7112104b5' aria-label='People Incorporated' aria-invalid='false' aria-required=true> <span>People Incorporated<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_ffc527efea924628c41216bba9e68261'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Goodwill Industries of the Valleys\"  id='checkbox_1_ffc527efea924628c41216bba9e68261' aria-label='Goodwill Industries of the Valleys' aria-invalid='false' aria-required=true> <span>Goodwill Industries of the Valleys<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_9fa9c628ddc2563dc902b70359abb71f'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NRCC Regional Adult Education Program\"  id='checkbox_1_9fa9c628ddc2563dc902b70359abb71f' aria-label='NRCC Regional Adult Education Program' aria-invalid='false' aria-required=true> <span>NRCC Regional Adult Education Program<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_9fadf4991438e5673cc31e309d5893b5'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mount Rogers Regional Adult Education Program\"  id='checkbox_1_9fadf4991438e5673cc31e309d5893b5' aria-label='Mount Rogers Regional Adult Education Program' aria-invalid='false' aria-required=true> <span>Mount Rogers Regional Adult Education Program<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_b169234d5a4b090e7a4b26861072b683'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Department of Social Services (specify below)\"  id='checkbox_1_b169234d5a4b090e7a4b26861072b683' aria-label='Department of Social Services (specify below)' aria-invalid='false' aria-required=true> <span>Department of Social Services (specify below)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_5c207626bbd4b578630c18a2ddd2333f'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Department for Aging and Rehabilitative Services\"  id='checkbox_1_5c207626bbd4b578630c18a2ddd2333f' aria-label='Department for Aging and Rehabilitative Services' aria-invalid='false' aria-required=true> <span>Department for Aging and Rehabilitative Services<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_946b67ba2cf742bc30cb30cc17e00a73'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"New River Community College\"  id='checkbox_1_946b67ba2cf742bc30cb30cc17e00a73' aria-label='New River Community College' aria-invalid='false' aria-required=true> <span>New River Community College<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_9cf63756ef0cea51f6489cadb58dd90d'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"New River Community College\"  id='checkbox_1_9cf63756ef0cea51f6489cadb58dd90d' aria-label='New River Community College' aria-invalid='false' aria-required=true> <span>New River Community College<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_984553ac131f603c58a269f004b83b36'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Virginia Highlands Community College\"  id='checkbox_1_984553ac131f603c58a269f004b83b36' aria-label='Virginia Highlands Community College' aria-invalid='false' aria-required=true> <span>Virginia Highlands Community College<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_47ac5194a3faad07674cf523277fa118'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Employer (specify below)\"  id='checkbox_1_47ac5194a3faad07674cf523277fa118' aria-label='Employer (specify below)' aria-invalid='false' aria-required=true> <span>Employer (specify below)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_5606ceef64d9b1dcfae48cc8d18d7fbf'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Trades Training Initiative\"  id='checkbox_1_5606ceef64d9b1dcfae48cc8d18d7fbf' aria-label='Trades Training Initiative' aria-invalid='false' aria-required=true> <span>Trades Training Initiative<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_573d22278d319d484d11418734ceb440'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Blue Ridge Job Corps\"  id='checkbox_1_573d22278d319d484d11418734ceb440' aria-label='Blue Ridge Job Corps' aria-invalid='false' aria-required=true> <span>Blue Ridge Job Corps<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_99d075a53db4c1da11c95a6994e4778b'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Virginia DOLI\"  id='checkbox_1_99d075a53db4c1da11c95a6994e4778b' aria-label='Virginia DOLI' aria-invalid='false' aria-required=true> <span>Virginia DOLI<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_54a1f2649b17511e8ca3cb9ddbae58a4'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other (specify below)\"  id='checkbox_1_54a1f2649b17511e8ca3cb9ddbae58a4' aria-label='Other (specify below)' aria-invalid='false' aria-required=true> <span>Other (specify below)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_3' id='label_ff_6_input_text_3' aria-label=\"Other\/Additional Information\">Other\/Additional Information<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_6_input_text_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff_list_2col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"I want this information to be exchanged only for the following purpose(s):\">I want this information to be exchanged only for the following purpose(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='checkbox_2_db93ed807e53156b642cbf5bacaa0da2'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Service Coordination\"  id='checkbox_2_db93ed807e53156b642cbf5bacaa0da2' aria-label='Service Coordination' aria-invalid='false' aria-required=true> <span>Service Coordination<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_ca72e62fbd857b3a13e2ea07c7002377'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Treatment Planning\"  id='checkbox_2_ca72e62fbd857b3a13e2ea07c7002377' aria-label='Treatment Planning' aria-invalid='false' aria-required=true> <span>Treatment Planning<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4594f214b7b914b1fb1b84a4acda71c6'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Eligibility Determination\"  id='checkbox_2_4594f214b7b914b1fb1b84a4acda71c6' aria-label='Eligibility Determination' aria-invalid='false' aria-required=true> <span>Eligibility Determination<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_c0d498393c3c3548de1970eb88a2800d'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Follow-up\"  id='checkbox_2_c0d498393c3c3548de1970eb88a2800d' aria-label='Follow-up' aria-invalid='false' aria-required=true> <span>Follow-up<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_0c166d980ee4c9ef1611f6ebb2285260'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other (specify below):\"  id='checkbox_2_0c166d980ee4c9ef1611f6ebb2285260' aria-label='Other (specify below):' aria-invalid='false' aria-required=true> <span>Other (specify below):<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_4' id='label_ff_6_input_text_4' aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_6_input_text_4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff_list_2col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"I want information to be shared: (check all that apply):\">I want information to be shared: (check all that apply):<\/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_3_224540be1521295740394556df3e2006'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Written Information\"  id='checkbox_3_224540be1521295740394556df3e2006' aria-label='Written Information' aria-invalid='false' aria-required=true> <span>Written Information<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_c1bc9aa2fb338220f45951315011fed5'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Meetings (in-person and virtual)\"  id='checkbox_3_c1bc9aa2fb338220f45951315011fed5' aria-label='Meetings (in-person and virtual)' aria-invalid='false' aria-required=true> <span>Meetings (in-person and virtual)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_cc36b7760251fb1d9e62aedceafa162a'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Phone\"  id='checkbox_3_cc36b7760251fb1d9e62aedceafa162a' aria-label='Phone' aria-invalid='false' aria-required=true> <span>Phone<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_c9dc9234b453204bfb0758fdce28bc15'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Computerized Data\"  id='checkbox_3_c9dc9234b453204bfb0758fdce28bc15' aria-label='Computerized Data' aria-invalid='false' aria-required=true> <span>Computerized Data<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_0af227321ecdc5ff2d30e8ac5b3f9eec'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other (specify below):\"  id='checkbox_3_0af227321ecdc5ff2d30e8ac5b3f9eec' aria-label='Other (specify below):' aria-invalid='false' aria-required=true> <span>Other (specify below):<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_5' id='label_ff_6_input_text_5' aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_6_input_text_5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_datetime' id='label_ff_6_datetime' aria-label=\"This Consent is Good Until:\">This Consent is Good Until:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='This Consent is Good Until: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_6_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-6_3\" ><p><em>I can withdraw this consent at any time by telling the referring agency. My withdrawal will stop the listed agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about me has been shared, as well as why, when, and with whom it was shared.<\/em><\/p>\n<p><em>If I ask, each agency will show me this information.<\/em><\/p>\n<p>I want all the agencies to accept a copy of this form as a valid consent to share information. If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they need.<\/p><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_names_first_name_' id='label_ff_6_names_first_name_' >Participant First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_6_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_names_last_name_' id='label_ff_6_names_last_name_' >Participant Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_6_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff_list_2col'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Particpant is under 18\">Particpant is under 18<\/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_148d7817baffc649d186796cf73eac6c'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_148d7817baffc649d186796cf73eac6c' 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_8e1c3d3cf9a02a14eecea94b60bbe8a7'><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_8e1c3d3cf9a02a14eecea94b60bbe8a7' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text_6' id='label_ff_6_input_text_6' aria-label=\"Electronic Signature\">Electronic Signature<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_6_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_datetime_1' id='label_ff_6_datetime_1' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_1\" id=\"ff_6_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_dropdown' id='label_ff_6_dropdown' aria-label=\"Relationship to the client:\">Relationship to the client:<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_6_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_6_dropdown\"><option value=\"\">- Select -<\/option><option value=\"Self\"  >Self<\/option><option value=\"Parent\"  >Parent<\/option><option value=\"Power of Attorney\"  >Power of Attorney<\/option><option value=\"Guardian\"  >Guardian<\/option><option value=\"Other Legally Authorized Representative\"  >Other Legally Authorized Representative<\/option><\/select><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Submit Form\">Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_6_errors' class='ff-errors-in-stack ff_form_instance_6_1 ff-form-loading_errors ff_form_instance_6_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_6_1 = {\"id\":\"6\",\"ajaxUrl\":\"https:\\\/\\\/wpdev.billychandler.com\\\/nrmr\\\/wp-admin\\\/admin-ajax.php\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_6_1\",\"form_id_selector\":\"fluentform_6\",\"rules\":{\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox_2\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_5\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"datetime\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[last_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"datetime_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"dropdown\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}}},\"debounce_time\":300,\"file_upload_settings\":[]};\n                            <\/script>\n            \n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":19,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page_full-width-container-noheaderimage.php","meta":{"episode_type":"","audio_file":"","podmotor_file_id":"","podmotor_episode_id":"","cover_image":"","cover_image_id":"","duration":"","filesize":"","filesize_raw":"","date_recorded":"","explicit":"","block":"","itunes_episode_number":"","itunes_title":"","itunes_season_number":"","itunes_episode_type":"","footnotes":""},"class_list":["post-473","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/pages\/473","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/comments?post=473"}],"version-history":[{"count":1,"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/pages\/473\/revisions"}],"predecessor-version":[{"id":474,"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/pages\/473\/revisions\/474"}],"up":[{"embeddable":true,"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/pages\/19"}],"wp:attachment":[{"href":"https:\/\/wpdev.billychandler.com\/nrmr\/wp-json\/wp\/v2\/media?parent=473"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}